Professional Documents
Culture Documents
Faculty Guide For Integrating Breastfeeding in University Curricula
Faculty Guide For Integrating Breastfeeding in University Curricula
www.mcfc.org.eg
UNIVERSITY CURRICULA
Dance
1
This is a MCFC/ UNICEF joint initiative with Egyptian universities emerging from the
consensus meetings conducted with faculties of medicine and nursing in Cairo
University on 5th May, 2016; AlAzhar University on 12th May, 2016; Benha University on
17th May, 2016 and High Institute of Public Health, Alexandria University on 18th May,
2016; in collaboration with MCH/MoHP-Egypt and supported by UNICEF Cairo office.
“Stunted children today means stunted economies tomorrow” There is strong evidence to show that better
early nutrition for children results in higher earnings later in life and contributes to overall economic
growth.
One quarter of all children around the world - 159 million - are stunted. This means that their bodies and
brains have not grown to their full potential. This puts them at a major disadvantage in learning and
acquiring life skills before they even set foot in school. This unequal start compromises their future
earnings, contributing to a life of insurmountable inequality. Investments in early nutrition are not just
crucial, they are also irrevocable, with benefits that last a lifetime. Investment of $7 billion annually, the
four costed targets could be fully achieved; with 3.7 million fewer child deaths and 65 million fewer
stunted children by 2025. The Investing in Nutrition report of the World Bank focuses on the first four,
(first hour of skin to skin contact and early initiation of breastfeeding) where evidence is the strongest.
“If I had to pick one investment that I could make that would be the most impactful, that would be
nutrition and especially breastfeeding,".
Competing in today's digital economy requires a workforce with well-developed brains. Governments that
don't invest in a skilled, healthy, productive workforce are harming their future prospects to compete in
the global economy.
"If you want to support the most vulnerable, you have to start at the foundation: nutrition. But if you want
to support the most vulnerable, you also have to focus on women and girls." Hence learning how other
sectors can be effectively mobilized; and making investments in areas like clean water, sanitation and
hygiene, social protection, and girls and women's education and empowerment, are all critical to
accelerating progress on nutrition.
Quotations excerpted by World Bank May 10th, 2016 and disseminated by officials during the openings of the university
meetings as rationale and justification for investing in this initiative.
To this end, MCFC supported by UNICEF office in Egypt conducted 4 scientific meetings with Cairo,
AlAzhar, Benha and Alexandria universities. The meetings highlighted the inconsistencies of teaching lactation
management among Egyptian medical and nursing faculties. The plenary sessions emphasized the importance of
teaching the subject in medical and nursing faculties and making their clinical setting Baby friendly for modelling
best practices in lactation management. Speakers and facilitators, agreed to recommend a standard minimum
curriculum for undergraduate medical and nursing students for lactation management in Egyptian universities.
Outcome from meetings:
The pediatric department of AlAzhar University (for girls) was the first to develop a model of integration of
Breastfeeding into the different specialties of pediatrics. Cairo university community medicine department was the
first to endorse an MOU in this respect. In Alexandria University the High Institute of Public Health is developing a
Diploma certificate program for certifying Lactation specialists and Kinder Garten Faculty is developing a Diploma
for nutrition and child health counselors. Benha University Pediatric and community medicine recommended
creating a center of excellence in partnership with the Qaluibiya Health Directorate for enhancing education in
Breastfeeding and Young Child Feeding. The current module was inspired by these meetings.
The aim of the current module is to:
1. Equip faculty staff with new evidence in Breastfeeding practice that would be important in teaching.
2. Equip faculty staff with effective methods of teaching lactation management to medical and nursing
students.
3. Provide resources for developing lactation management curriculum.
4. Motivate faculty staff to develop and enhance existing lactation management curricula in their own
institutions.
Table of Contents
Pretest 3
Session 1 The importance of infant and young child feeding and recommended practices
Introduction 8
Pretest
Session 1 The importance of infant and young child feeding and recommended practices 9
Session 2 The physiological basis of breastfeeding 15
Session 3 Supportfor
Skills forsupport
infant and of
young child and
infant feedingyoung child feeding 25
Session 4 Management and support of infant feeding in maternity facilities 39
Session 5 Complementary feeding 47
Session 6 Appropriate feeding in exceptionally difficult circumstances 57
Session 7 Management of breast conditions and other breastfeeding difficulties 71
Session 8 Mother’s health 85
Session 9 Policy, health system and community actions 91
Post-test 99
Annexes
Annex 1 Acceptable medical reasons for use of breast-milk substitutes 103
Annex 2 WHO Growth standards 89
105
Annex 3 Models for process of becoming Baby friendly 107
Annex 4 WHO Algorithms for integrating Safe Childbirth with Baby and Mother Friendly practices 108
Annex 5 Indicators for assessing infant and young child feeding practices 110
Annex 6 Models of Integration of Breastfeeding in university curriculum (Pediatrics and Public Health) 111
Annex 7 Competencies in Breastfeeding management (medical and nursing) 117
Key to pre and post tests 119
Faculty Guide to integration Breastfeeding in University Curricula
4
Pre-test
_________________________________
Please circle only one appropriate c. baby’s suck is too strong
response: d. lack of nipple preparation
during pregnancy
1. Identify the component of human
milk that binds iron locally to 6. The hormone considered
inhibit bacterial growth: responsible for milk synthesis is:
a. taurine a. progesterone
b. secretory IgA b. prolactin
c. macrophages c. estrogen
d. lactoferrin d. oxytocin
e. oligosaccharides
7. Which of the following would you
2. The most important criterion for suggest that a woman with
assessing the milk transfer during inverted nipples do during the
third trimester?
a feeding at the breast is:
a. Use breast shells with
a. visible areola
guidance from her health
compression
care provider
b. audible swallow
b. Cut holes in the bra to allow
c. proper alignment
the nipples to protrude; wear
d. proper attachment
it day and night
c. Encourage everting the
3. Compared to formula, human milk
nipples four times a day to
contains higher levels of:
permanently evert her
a. vitamin D
nipples
b. iron
d. Do nothing because the
c. lipase
natural changes in the
d. vitamin A
breast during pregnancy
e. none of the above
and the infant’s suckling
4. The hormone considered postpartum may evert
responsible for milk ejection is: the nipples
a. progesterone
b. prolactin 8. Which of the following is most
c. estrogen likely to have the greatest
d. oxytocin negative effect on the volume
5. A mother with a three-day old of milk a woman produces?
baby presents with sore nipples. a. maternal weight for height
The problem began with the first b. maternal fluid intake
feeding and has persisted with c. supplementation of the
every feeding. The most likely infant with formula
source of the problem is: d. maternal caloric intake
a. feeding too long e. both a and c
b. poor attachment
9. Infants exclusively breastfed for
about six months will have:
problems
b. maternal nutritional
5
a. Fewer episodes of lower deficiencies
respiratory infection c. infant metabolic
b. fewer episodes of diarrhea disorders
c. none of the above d. infrequent or ineffective
d. both a and b above feedings
10. The addition of complementary e. low fat content of breast
foods to breastfed infants is milk
recommended at about: 15. A breastfeeding mother with a 3-
a. 2 months month old infant has a red tender
b. 4 months wedge-shaped area on the outer
c. 6 months quadrant of one breast. She has
d. 8 months flu-like symptoms and a
e. 10 months temperature of 39C. Your
management includes all of the
11. Signs of adequate breast milk following EXCEPT:
intake in the early (first 4-6) weeks a. extra rest
include all EXCEPT: b. interrupt breastfeeding
a. baby gains weight for 48 hours
b. at least 3-4 stools in 24 c. moist heat to the
hours involved region
c. sounds of swallowing d. antibiotics for 10 to 14
d. baby sleeps through the days days
night
e. at least 6 diapers wet 16. Studies have indicated that the
with urine in 24 hours Lactational Amenorrhea
Method (LAM) of
12. It is especially important that contraception is less reliable
an infant with a strong family under which of the following
history of allergy should be circumstances:
exclusively breastfed for: a. feeds 8 or more times in
a. 2 months 24 hours
b. 4 months b. is given no regular
c. 6 months supplements
d. 8 months c. is less than 8 months old
e. 10 months d. continues with night
feedings
13. Severe engorgement is most often
due to: 17. Which of the following
a. high oxytocin level statements is not true of The
b. infrequent feedings International Code of Marketing
c. high prolactin level of Breastmilk Substitutes
d. postpartum depression approved as a resolution in the
World Health Assembly (WHA)
14. The most common cause of poor in 1981:
weight gain among breastfed a. is updated every two years
infants during the first four weeks by the WHA
after birth is: b. provides guidelines for the
a. maternal endocrine ethical marketing of infant
formula
Faculty Guide to integration Breastfeeding in University Curricula
6 c. is incorporated into the Baby environment for infants and young
Friendly Hospital children
assessment
d. was approved by all WHA 22. Hospital policies that promote
member countries breastfeeding include:
e. includes bottles, nipples, and a. use of a dropper for routine
breastmilk substitutes water supplementation
b. uninterrupted sleep the first
18. Nipple candidiasis can be night to allow mother’s milk
associated with all of the following supply to build up
EXCEPT: c. unlimited access of mother to
a. oral thrush in the infant baby
b. burning pain in the breast d. use of pacifiers to prevent sore
c. fever and malaise nipples
d. pink and shiny appearance
of the nipples and areola 23. Through 27. Label the structures
of the breast by inserting next to
19. Jaundice in a normal full term the appropriate pointer the number
breastfeeding infant is improved of the structure listed below:
by: 23. Montgomery’s glands
a. giving glucose water after 24. Supporting fat and other
breastfeeding tissues
b. giving water after 25. Alveoli
breastfeeding 26. Areola
c. breastfeeding frequently (at 27. Duct
least 8 or more times in 24
hours)
d. both a and c
21. Reasons for including breast- 28. All of the following are recommended
feeding support for mother-infant when to encourage successful breastfeeding
planning for major emergencies where EXCEPT:
clean water, sanitation and power are a) Initiation of breastfeeding within 1
hour of birth
disrupted do not include:
b) Avoiding the use of pacifiers and
a. To make sure the donations of infant artificial nipples in term
milk formula go to the needy mothers breastfeeding infants
b. With support even mothers who have c) Continuous rooming in with
already weaned can be assisted to breastfeeding on demand
relactate d) Restricting length of breastfeeding
a.Breastmilk provides immunoglobulins time to prevent nipple soreness and
that actively prevent infection. engorgement
b.In a stressful emergency situation e) Avoiding use of supplemental
breastfeeding provides a secure formula during the early stages of
milk production c. allergic sensitization
d. pneumonia
7
29. Which of the following is a e. 12 months
correct statement about the latch
during breastfeeding? 34. Breast milk jaundice is BEST
a) The baby must take all of the areola characterized by:
into the mouth to achieve a good a. Weight loss
latch b. Poor feeding
b) A narrow angle at the corner of the c. Brick dust urine
infant’s mouth is indicative of a d. A high direct bilirubin
good latch e. A thriving infant with persistent
c) The baby needs to be latched so that jaundice
he compresses the milk ducts under
the areola when suckling at the 35. Breastfeeding is contraindicated in
breast which of the following conditions:
d) The baby needs to be latched so that a. Maternal irradiation therapy
he compresses the base of the nipple b. Maternal Hepatitis B
not areola when feeding c. Maternal Hepatitis C
e) Mothers who have had previous d. Maternal mastitis
breastfeeding experience rarely e. Infants with Cystic Fibrosis
require assessment of the baby’s
latch in the hospital or birthing 36. A mother with a 3-day-old baby
center presents with sore nipples. The
most likely source of the
30- Compared with mature milk, problem is:
colostrum is: a. Baby’s suck is too strong
a) Lower in sodium, potassium and b. Feeding time is too long
chloride c. Lack of nipple preparation during
b) Higher in fat and sodium pregnancy
c) Higher in protein, sodium, and fat d. Inverted nipples
soluble vitamins e. Poor attachment to the breast
d) Lower in fat and carotenoids 37. Signs of milk ejection in the first few
e) Higher in water-soluble vitamins weeks include all of the following
EXCEPT:
31. Severe engorgement is prevented by
all EXCEPT: a) Milk leaking from the other breast
a. Early initiation of breastfeeding
b) Uterine cramping
b. Frequent feedings
c. Postpartum rooming-in c) Breast erythema
d. Increasing fluid intake d) Hunger sensation
e. Correct latch-on
e) “Pins and needles” sensation in the
32. The most common cause of poor breast
weight gain among breastfed infants 38. All of the following will influence
during the first 4 weeks after birth is: maternal milk production EXCEPT:
a. Infant metabolic disorders a) Retained placental fragments
b. Infrequent or ineffective feedings
c. Low fat content of breast milk b) Maternal smoking
d. Maternal endocrine problems c) Maternal fatigue and stress
e. Maternal nutritional deficiencies
d) Praising and empathizing with mother
33. Prelacteal feeds can cause: e) Diuretic medications
a. hypoglycemia
b. hypothermia
Faculty Guide to integration Breastfeeding in University Curricula
8
Introduction
breastfeed. However we cannot put all the blame on
Optimal infant and young child feeding practices rank
the industry, since the medical curricula are very
among the most effective interventions to improve
deficient in material pertaining to breastfeeding,
child health. In 2006 an estimated 9.5 million children
especially those related to practical and clinical
died before their fifth birthday, and two thirds of
management skills and techniques in breastfeeding.
these deaths occurred in the first year of life. Under-
nutrition is associated with at least 35% of child deaths. The developments in breastfeeding management have
It is also a major disabler preventing children who been escalating over the past decades and with the
survive from reaching their full developmental growth of professional organizations, specialists and
potential. Around 32% of children less than 5 years researchers in this field there are now over 100 million
of age in developing countries are stunted and 10% research articles in this field. Moreover there are
are wasted. It is estimated that sub-optimal breast- hundreds academic or scientific or community
feeding, especially non-exclusive breastfeeding in the organization world-wide working in this field.
first 6 months of life, results in 1.4 million deaths and Although reference textbooks in the major fields of
10% of the disease burden in children younger than 5 nutrition, pediatrics, obstetrics and community
years. medicine have expanded their chapters in this field,
the university and teaching curricula in our region still
To improve this situation, mothers and families need
follow the traditionally taught information and have
support to initiate and sustain appropriate infant and
not revisited their teaching methods to meet the
young child feeding practices. Health care profession-
emerging needs that have changed the health care
also can play a critical role in providing that support,
management and specialist training in the west.
through influencing decisions about feeding practices
among mothers and families. Therefore, it is critical This Faculty Guide in Infant & Young Child Feeding
for health professionals to have basic knowledge and (FG-IYCF) brings together essential knowledge about
skills to give appropriate advice, counsel and help infant and young child feeding that health
solve feeding difficulties, and know when and where professionals should acquire as part of their basic
to refer a mother who experiences more complex education. It focuses on nutritional needs and feeding
feeding problems. practices in children less than 2 years of age – the
most critical period for child nutrition after which
Child health in general, and infant and young child
sub-optimal growth is hard to reverse. The Chapter
feeding more specifically is often not well addressed
does not impart skills, although it includes
in the basic training of doctors, nurses and other
descriptions of essential skills that every health
allied health professionals. Because of lack of adequate
professional should master, such as positioning and
knowledge and skills, health professionals are often
attachment for breastfeeding.
barriers to improved feeding practices. For example,
they may not know how to assist a mother to initiate The Faculty Guide in IYCF is organized in nine
and sustain exclusive breastfeeding, they may sessions according to topic areas, with take home
recommend too-early introduction of supplements messages and knowledge test activities at the end of
when there are feeding problems, and they may each section. The references included in the original
overtly or covertly promote breast-milk substitutes. document have been minimized and can be referred to
by visiting the publication section in the WHO web
Faculty members, particularly working in neonatal
site to review the original material or our web site
and pediatric units are a target to the Infant Milk
(mcfc.org.eg). It also include articles or WHO
Formula companies. They rely on these companies to
documents that provide evidence and further
sponsor their scientific meetings and obtain all the
information about specific points.
information of infant feeding from the material they
distribute and present to them in these meetings. They
become indebted to these companies and end up
prescribing and promoting their products instead of
supporting their clients to breastfeed and finding new
techniques and therapies to help them continue to
9
The importance of infant and young child
SeSSIon 1
feeding and recommended practices
Adequate nutrition during infan- Deaths among children under five Neonatal deaths
cy and early childhood is essen-
Noncommunicable diseases Other 9%
tial to ensure the growth, health, (postneonatal) 4%
Other infectious and Congenital anomalies 7%
and development of children to parasitic diseases 9% Injuries (postneonatal) 4% Neonatal tetanus 3%
Diarrhoeal diseases 3%
their full potential. Poor nutrition HIV/AIDS 2%
Neonatal infections 25%
increases the risk of illness, and is Measles 4%
responsible, directly or indirectly, Malaria 7%
Neonatal
deaths Birth asphyxia and
for one third of the estimated 37% birth trauma 23%
9.5 million deaths that occurred Diarrhoeal diseases
(postneonatal) 16%
Prematurity and
in 2006 in children less than 5 low birth weight 31%
years of age (1,2) (Figure 1). Inap- Acute respiratory
infections (postneonatal)
propriate nutrition can also lead 17% 35% of under-five deaths are due to the presence of undernutrition
to childhood obesity which is an
increasing public health problem sources: World Health organization. The global burden of disease: 2004 update. Geneva, World Health organization,
in many countries. 2008; Black R et al. Maternal and child undernutrition: global and regional exposures and health consequences.
Lancet, 2008, 371:243–260.
Early nutritional deficits are also Source: Countdown to 2015 2010 Report
linked to long-term impairment in growth and health. 1.2 The Global Strategy for infant and
Malnutrition during the first 2 years of life causes young child feeding
stunting, leading to the adult being several centime-
In 2002, the World Health Organization and UNICEF
tres shorter than his or her potential height (3). There
adopted the Global Strategy for infant and young child
is evidence that adults who were malnourished in ear-
feeding (10). The strategy was developed to revitalise
ly childhood have impaired intellectual performance
world attention to the impact that feeding practices
(4). They may also have reduced capacity for physical
have on the nutritional status, growth and devel-
work (5,6). If women were malnourished as children,
opment, health, and survival of infants and young
their reproductive capacity is affected, their infants
children (see also Session 9). This Model Chapter sum-
may have lower birth weight, and they have more
marizes essential knowledge that every health profes-
complicated deliveries (7). When many children in a
sional should have in order to carry out the crucial
population are malnourished, it has implications for
role of protecting, promoting and supporting appro-
national development. The overall functional conse-
priate infant and young child feeding in accordance
quences of malnutrition are thus immense.
with the principles of the Global Strategy.
The first two years of life provide a critical window
of opportunity for ensuring children’s appropri- 1.3 Recommended infant and young child feeding
ate growth and development through optimal feed- practices
ing (8). Based on evidence of the effectiveness of WHO and UNICEF’s global recommendations for
interventions, achievement of universal coverage of optimal infant feeding as set out in the Global Strat-
optimal breastfeeding could prevent 13% of deaths egy are:
occurring in children less than 5 years of age globally,
while appropriate complementary feeding practices K exclusive breastfeeding for 6 months (180 days)
would result in an additional 6% reduction in under- (11);
five mortality (9).
Faculty Guide to integration Breastfeeding in University Curricula
10
4 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
FIGuRe 2
Trends in exclusive breastfeeding rates (1996–2006)
50
44 45 around 1996
Percentage of infants exclusively breastfed
40 37 around 2006
for the first six months of life
32 33
30 30
30 27
26
22
20 19
10
10
0
CEE/CIS Middle East/ Sub-Saharan East Asia/Pacific South Asia Developing countries
North Africa Africa (excluding China) (excluding China)
source: unICeF. Progress for children: a world fit for children. Statistical Review, Number 6. new York, unICeF, 2007.
K nutritionally adequate and safe complementary foods are often introduced too early or too late and are
feeding starting from the age of 6 months with con- often nutritionally inadequate and unsafe.
tinued breastfeeding up to 2 years of age or beyond.
Data from 64 countries covering 69% of births in
Exclusive breastfeeding means that an infant receives the developing world suggest that there have been
only breast milk from his or her mother or a wet improvements in this situation. Between 1996 and
nurse, or expressed breast milk, and no other liquids 2006 the rate of exclusive breastfeeding for the first
or solids, not even water, with the exception of oral 6 months of life increased from 33% to 37%. Sig-
rehydration solution, drops or syrups consisting of nificant increases were made in sub-Saharan Africa,
vitamins, minerals supplements or medicines (12). where rates increased from 22% to 30%; and Europe,
with rates increasing from 10% to 19% (Figure 2). In
Complementary feeding is defined as the process start-
Latin America and the Caribbean, excluding Bra-
ing when breast milk is no longer sufficient to meet the
zil and Mexico, the percentage of infants exclusively
nutritional requirements of infants, and therefore oth-
breastfed increased from 30% in around 1996 to 45%
er foods and liquids are needed, along with breast milk.
in around 2006 (15).
The target range for complementary feeding is gener-
ally taken to be 6 to 23 months of age,1 even though
breastfeeding may continue beyond two years (13). 1.5 evidence for recommended feeding practices
These recommendations may be adapted according Breastfeeding
to the needs of infants and young children in excep- Breastfeeding confers short-term and long-term
tionally difficult circumstances, such as pre-term benefits on both child and mother (16), including
or low-birth-weight infants, severely malnourished helping to protect children against a variety of acute
children, and in emergency situations (see Session 6). and chronic disorders. The long-term disadvantages
Specific recommendations apply to infants born to of not breastfeeding are increasingly recognized as
HIV-infected mothers. important (17,18).
Reviews of studies from developing countries show
1.4 Current status of infant and young child that infants who are not breastfed are 6 (19) to 10
feeding globally times (20) more likely to die in the first months of life
Poor breastfeeding and complementary feeding prac- than infants who are breastfed. Diarrhoea (21) and
tices are widespread. Worldwide, it is estimated that pneumonia (22) are more common and more severe
only 34.8% of infants are exclusively breastfed for the in children who are artificially fed, and are responsi-
first 6 months of life, the majority receiving some other ble for many of these deaths. Diarrhoeal illness is also
food or fluid in the early months (14). Complementary more common in artificially-fed infants even in situ-
ations with adequate hygiene, as in Belarus (23) and
1
When describing age ranges, a child 6–23 months has complet- Scotland (24). Other acute infections, including otitis
ed 6 months but has an age less than 2 years. media (25), Haemophilus influenzae meningitis (26),
1. THe IMPoRTAnCe oF InFAnT And YounG CHIld FeedInG And ReCoMMended PRACTICes 11
5
and urinary tract infection (27), are less common and were exclusively instead of partially breastfed for the
less severe in breastfed infants. first 4 months of life (48). Exclusive breastfeeding for 6
months has been found to reduce the risk of diarrhoea
Artificially-fed children have an increased risk of long-
(49) and respiratory illness (50) compared with exclu-
term diseases with an immunological basis, including
sive breastfeeding for 3 and 4 months respectively.
asthma and other atopic conditions (28,29), type 1
diabetes (30), celiac disease (31), ulcerative colitis and If the breastfeeding technique is satisfactory, exclu-
Crohn disease (32). Artificial feeding is also associ- sive breastfeeding for the first 6 months of life meets
ated with a greater risk of childhood leukaemia (33). the energy and nutrient needs of the vast majority of
infants (51). No other foods or fluids are necessary.
Several studies suggest that obesity in later childhood
Several studies have shown that healthy infants do
and adolescence is less common among breastfed chil-
not need additional water during the first 6 months
dren, and that there is a dose response effect, with a
if they are exclusively breastfed, even in a hot climate.
longer duration of breastfeeding associated with a low-
Breast milk itself is 88% water, and is enough to sat-
er risk (34,35). The effect may be less clear in popula-
isfy a baby’s thirst (52). Extra fluids displace breast
tions where some children are undernourished (36). A
milk, and do not increase overall intake (53). How-
growing body of evidence links artificial feeding with
ever, water and teas are commonly given to infants,
risks to cardiovascular health, including increased
often starting in the first week of life. This practice
blood pressure (37), altered blood cholesterol levels
has been associated with a two-fold increased risk of
(38) and atherosclerosis in later adulthood (39).
diarrhoea (54).
Regarding intelligence, a meta-analysis of 20 studies
For the mother, exclusive breastfeeding can delay
(40) showed scores of cognitive function on average
the return of fertility (55), and accelerate recovery of
3.2 points higher among children who were breastfed
pre-pregnancy weight (56). Mothers who breastfeed
compared with those who were formula fed. The dif-
exclusively and frequently have less than a 2% risk of
ference was greater (by 5.18 points) among those chil-
becoming pregnant in the first 6 months postpartum,
dren who were born with low birth weight. Increased
provided that they still have amenorrhoea (see Session
duration of breastfeeding has been associated with
8.4.1).
greater intelligence in late childhood (41) and adult-
hood (42), which may affect the individual’s ability to
contribute to society. Complementary feeding from 6 months
From the age of 6 months, an infant’s need for energy
For the mother, breastfeeding also has both short- and
and nutrients starts to exceed what is provided by
long-term benefits. The risk of postpartum haemor-
breast milk, and complementary feeding becomes
rhage may be reduced by breastfeeding immediately
necessary to fill the energy and nutrient gap (57). If
after delivery (43), and there is increasing evidence
complementary foods are not introduced at this age
that the risk of breast (44) and ovarian (45) cancer is
or if they are given inappropriately, an infant’s growth
less among women who breastfed.
may falter. In many countries, the period of comple-
mentary feeding from 6–23 months is the time of
Exclusive breastfeeding for 6 months peak incidence of growth faltering, micronutrient
The advantages of exclusive breastfeeding compared deficiencies and infectious illnesses (58).
to partial breastfeeding were recognised in 1984,
Even after complementary foods have been intro-
when a review of available studies found that the risk
duced, breastfeeding remains a critical source of
of death from diarrhoea of partially breastfed infants
nutrients for the young infant and child. It provides
0–6 months of age was 8.6 times the risk for exclu-
about one half of an infant’s energy needs up to the
sively breastfed children. For those who received no
age of one year, and up to one third during the second
breast milk the risk was 25 times that of those who
year of life. Breast milk continues to supply higher
were exclusively breastfed (46). A study in Brazil in
quality nutrients than complementary foods, and also
1987 found that compared with exclusive breastfeed-
protective factors. It is therefore recommended that
ing, partial breastfeeding was associated with 4.2
breastfeeding on demand continues with adequate
times the risk of death, while no breastfeeding had
complementary feeding up to 2 years or beyond (13).
14.2 times the risk (47). More recently, a study in Dha-
ka, Bangladesh found that deaths from diarrhoea and Complementary foods need to be nutritionally-
pneumonia could be reduced by one third if infants adequate, safe, and appropriately fed in order to meet
Faculty Guide to integration Breastfeeding in University Curricula
12
6 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
the young child’s energy and nutrient needs. How- 12. WHO/UNICEF/USAID. Indicators for assessing
ever, complementary feeding is often fraught with infant and young child feeding practices. Geneva,
problems, with foods being too dilute, not fed often World Health Organization, 2008.
enough or in too small amounts, or replacing breast
13. PAHO/WHO. Guiding principles for complemen-
milk while being of an inferior quality. Both food and
tary feeding of the breastfed child. Washington
feeding practices influence the quality of complemen-
DC, Pan American Health Organization/World
tary feeding, and mothers and families need support
Health Organization, 2002.
to practise good complementary feeding (13).
14. WHO Global Data Bank on Infant and Young
References Child Feeding, 2009.
1. World Health Organization. The global burden 15. UNICEF. Progress for children: a world fit for chil-
of disease: 2004 update. Geneva, World Health dren. Statistical Review Number 6. New York,
Organization, 2008. UNICEF, 2007.
2. Black RE et al. Maternal and child undernutri- 16. Leon-Cava N et al. Quantifying the benefits of breast-
tion: global and regional exposures and health feeding: a summary of the evidence. Washington
consequences. Lancet, 2008, 371:243–60. DC, Pan American Health Organization, 2002.
3. Martorell R, Kettel Khan L, Schroeder DG. 17. Fewtrell MS. The long-term benefits of having been
Reversibility of stunting: epidemiological find- breastfed. Current Paediatrics, 2004, 14:97–103.
ings in children from developing countries.
18. WHO. Evidence on the long-term effects of breast-
European Journal of Clinical Nutrition, 1994, 58
feeding: systematic reviews and meta-analyses.
(Suppl.1):S45–S57.
Geneva, World Health Organization, 2007.
4. Pollitt E et al. Nutrition in early life and the ful-
19. WHO Collaborative Study Team on the Role of
filment of intellectual potential. The Journal of
Breastfeeding on the Prevention of Infant Mor-
Nutrition, 1995, 125:1111S–1118S.
tality. Effect of breastfeeding on infant and child-
5. Grantham-McGregor SM, Cumper G. Jamai- hood mortality due to infectious diseases in less
can studies in nutrition and child development, developed countries: a pooled analysis. Lancet,
and their implications for national development. 2000, 355:451–455.
The Proceedings of the Nutrition Society, 1992, 51:
20. Bahl R et al. Infant feeding patterns and risks of
71–79.
death and hospitalization in the first half of infan-
6. Haas JD et al. Early nutrition and later physical cy: multicentre cohort study. Bulletin of the World
work capacity. Nutrition reviews, 1996, 54(2,Pt2): Health Organization, 2005, 83:418–426.
S41–48.
21. De Zoysa I, Rea M, Martines J. Why promote
7. Martin RM et al. Parents’ growth in childhood breast feeding in diarrhoeal disease control pro-
and the birth weight of their offspring. Epidemiol- grammes? Health Policy and Planning, 1991,
ogy, 2004, 15:308–316. 6:371–379.
8. World Bank. Repositioning nutrition as central 22. Bachrach VR, Schwarz E, Bachrach LR. Breast-
to development: a strategy for large scale action. feeding and the risk of hospitalization for respira-
Washington DC, The World Bank, 2006. tory diseases in infancy: a meta-analysis. Archives
of Pediatrics and Adolescent Medicine, 2003,
9. Jones G et al. How many child deaths can we pre-
157:237–243.
vent this year? Lancet, 2003, 362:65–71.
23. Kramer MS et al. Promotion of Breastfeeding
10. WHO/UNICEF. Global strategy for infant and
Intervention Trial (PROBIT): a randomized trial
young child feeding. Geneva, World Health Organ-
in the Republic of Belarus. Journal of the American
ization, 2003.
Medical Association, 2001, 285:413–420.
11. Kramer MS, Kakuma R. The optimal duration of
24. Howie PW et al. Protective effect of breastfeeding
exclusive breastfeeding: a systematic review. Gene-
against infection. British Medical Journal, 1990,
va, World Health Organization, 2001 (WHO/
300:11–16.
NHD/01.08; WHO/FCH/01.23).
References: (refer to more references from the original document of WHO IYCF model chapter) 13
Take home messages for session 1:
The importance of infant and young child feeding and recommended practices
____________________________________________________________________________________
Test your knowledge
1) Breastfeeding has been associated with the a) Formula feeding exclusively
following health benefits:
b) Breastfeeding exclusively
a) A reduction in otitis media
c) Breastfeeding with formula supplement
b) A reduction in lower respiratory illness
d) Make no recommendation/support mother’s choice
c) A reduction in gastroenteritis
d) A reduction in hospitalization from any cause
3) For approximately what length of time do you
e) All of the above recommend exclusive breastfeeding?
a) 2 months
2) When discussing feeding options with parents of b) 4 months
healthy full-term infants in your practice, which one
c) 6 months
of the following do you usually recommend for the
first month of life? d) 9 months
Faculty Guide to integration Breastfeeding in University Curricula
14 4) Non-communicable diseases that can be increased
by artificial feeding include all EXCEPT:
a) Found no correlation between IQ and breastfeeding
duration in full-term infants
a) Otitis media b) Found no correlation between IQ and breast milk
intake in preterm infants
b) Type I Diabetes mellitus
c) Found a a statistically significant increase, in IQ in
c) Leukaemia
breastfed infants that increases with duration of
d) Celiac disease breastfeeding and with age
5) Although some older studies found a correlation d) Found breastfed infants have a 13–15 IQ point
between breastfeeding and higher intelligence, more advantage over artificially fed infants
recent studies, which controlled or adjusted for
maternal education, socio-economic status, and
related factors have:
SeSSIon 2
2.1 Breast-milk composition a baby. The concentration of protein in breast milk
Breast milk contains all the nutrients that an infant (0.9 g per 100 ml) is lower than in animal milks. The
needs in the first 6 months of life, including fat, car- much higher protein in animal milks can overload
bohydrates, proteins, vitamins, minerals and water the infant’s immature kidneys with waste nitrogen
(1,2,3,4). It is easily digested and efficiently used. products. Breast milk contains less of the protein
Breast milk also contains bioactive factors that aug- casein, and this casein in breast milk has a different
ment the infant’s immature immune system, provid- molecular structure. It forms much softer, more eas-
ing protection against infection, and other factors ily-digested curds than that in other milks. Among
that help digestion and absorption of nutrients. the whey, or soluble proteins, human milk contains
more alpha-lactalbumin; cow milk contains beta-
lactoglobulin, which is absent from human milk and
Fats
to which infants can become intolerant (4).
Breast milk contains about 3.5 g of fat per 100 ml of
milk, which provides about one half of the energy
Vitamins and minerals
content of the milk. The fat is secreted in small drop-
lets, and the amount increases as the feed progresses. Breast milk normally contains sufficient vitamins for
As a result, the hindmilk secreted towards the end of an infant, unless the mother herself is deficient (5).
a feed is rich in fat and looks creamy white, while the The exception is vitamin D. The infant needs expo-
foremilk at the beginning of a feed contains less fat and sure to sunlight to generate endogenous vitamin D –
looks somewhat bluish-grey in colour. Breast-milk or, if this is not possible, a supplement. The minerals
fat contains long chain polyunsaturated fatty acids iron and zinc are present in relatively low concentra-
(docosahexaenoic acid or DHA, and arachidonic acid tion, but their bioavailability and absorption is high.
or ARA) that are not available in other milks. These Provided that maternal iron status is adequate, term
fatty acids are important for the neurological devel- infants are born with a store of iron to supply their
opment of a child. DHA and ARA are added to some needs; only infants born with low birth weight may
varieties of infant formula, but this does not confer need supplements before 6 months. Delaying clamp-
any advantage over breast milk, and may not be as ing of the cord until pulsations have stopped (approxi-
effective as those in breast milk. mately 3 minutes) has been shown to improve infants’
iron status during the first 6 months of life (6,7).
Carbohydrates
Anti-infective factors
The main carbohydrate is the special milk sugar lac-
tose, a disaccharide. Breast milk contains about 7 g Breast milk contains many factors that help to protect
lactose per 100 ml, which is more than in most other an infant against infection (8) including:
milks, and is another important source of energy. K immunoglobulin, principally secretory immuno-
Another kind of carbohydrate present in breast milk globulin A (sIgA), which coats the intestinal mucosa
is oligosaccharides, or sugar chains, which provide and prevents bacteria from entering the cells;
important protection against infection (4).
K white blood cells which can kill micro-organisms;
The protection provided by these factors is unique- 2.3 Animal milks and infant formula
ly valuable for an infant. First, they protect without Animal milks are very different from breast milk
causing the effects of inflammation, such as fever, in both the quantities of the various nutrients, and
which can be dangerous for a young infant. Second, in their quality. For infants under 6 months of age,
sIgA contains antibodies formed in the mother’s body animal milks can be home-modified by the addition
against the bacteria in her gut, and against infections of water, sugar and micronutrients to make them
that she has encountered, so they protect against bac- usable as short-term replacements for breast milk in
teria that are particularly likely to be in the baby’s exceptionally difficult situations, but they can never
environment. be equivalent or have the same anti-infective proper-
ties as breast milk (13). After 6 months, infants can
Other bioactive factors receive boiled full cream milk (14).
Bile-salt stimulated lipase facilitates the complete
Infant formula is usually made from industrially-
digestion of fat once the milk has reached the small
modified cow milk or soy products. During the
intestine (9). Fat in artificial milks is less completely
manufacturing process the quantities of nutrients are
digested (4).
adjusted to make them more comparable to breast
Epidermal growth factor (10) stimulates maturation of milk. However, the qualitative differences in the fat
the lining of the infant’s intestine, so that it is better and protein cannot be altered, and the absence of
able to digest and absorb nutrients, and is less easily anti-infective and bio-active factors remain. Pow-
infected or sensitised to foreign proteins. It has been dered infant formula is not a sterile product, and may
suggested that other growth factors present in human be unsafe in other ways. Life threatening infections
milk target the development and maturation of nerves in newborns have been traced to contamination with
and retina (11). pathogenic bacteria, such as Enterobacter sakazakii,
found in powdered formula (15). Soy formula con-
2.2 Colostrum and mature milk tains phyto-oestrogens, with activity similar to the
Colostrum is the special milk that is secreted in the human hormone oestrogen, which could potentially
first 2–3 days after delivery. It is produced in small reduce fertility in boys and bring early puberty in
amounts, about 40–50 ml on the first day (12), but is girls (16).
all that an infant normally needs at this time. Colos-
trum is rich in white cells and antibodies, especially 2.4 Anatomy of the breast
sIgA, and it contains a larger percentage of protein, The breast structure (Figure 3) includes the nipple and
minerals and fat-soluble vitamins (A, E and K) than areola, mammary tissue, supporting connective tis-
later milk (2). Vitamin A is important for protection sue and fat, blood and lymphatic vessels, and nerves
of the eye and for the integrity of epithelial surfaces, (17,18).
and often makes the colostrum yellowish in colour.
The mammary tissue – This tissue includes the alveoli,
Colostrum provides important immune protection
which are small sacs made of milk-secreting cells, and
to an infant when he or she is first exposed to the
the ducts that carry the milk to the outside. Between
micro-organisms in the environment, and epidermal
feeds, milk collects in the lumen of the alveoli and
growth factor helps to prepare the lining of the gut
ducts. The alveoli are surrounded by a basket of
to receive the nutrients in milk. It is important that
myoepithelial, or muscle cells, which contract and
infants receive colostrum, and not other feeds, at this
make the milk flow along the ducts.
time. Other feeds given before breastfeeding is estab-
lished are called prelacteal feeds. Nipple and areola – The nipple has an average of nine
milk ducts passing to the outside, and also muscle
Milk starts to be produced in larger amounts between
fibres and nerves. The nipple is surrounded by the
2 and 4 days after delivery, making the breasts feel
circular pigmented areola, in which are located Mont-
full; the milk is then said to have “come in”. On the
gomery’s glands. These glands secrete an oily fluid that
third day, an infant is normally taking about 300–400
protects the skin of the nipple and areola during lac-
ml per 24 hours, and on the fifth day 500–800 ml (12).
tation, and produce the mother’s individual scent that
From day 7 to 14, the milk is called transitional, and
attracts her baby to the breast. The ducts beneath the
after 2 weeks it is called mature milk.
areola fill with milk and become wider during a feed,
when the oxytocin reflex is active.
2. THe PHYsIoloGICAl BAsIs oF BReAsTFeedInG 17
11
FIGuRe 3 FIGuRe 4
Anatomy of the breast Prolactin
Sensory impulses
from nipples
Prolactin
in blood
2.5 Hormonal control of milk production More prolactin is produced at night, so breastfeeding
There are two hormones that directly affect breast- at night is especially helpful for keeping up the milk
feeding: prolactin and oxytocin. A number of other supply. Prolactin seems to make a mother feel relaxed
hormones, such as oestrogen, are involved indirectly in and sleepy, so she usually rests well even if she breast-
lactation (2). When a baby suckles at the breast, sensory feeds at night.
impulses pass from the nipple to the brain. In response, Suckling affects the release of other pituitary hor-
the anterior lobe of the pituitary gland secretes prolac- mones, including gonadotrophin releasing hormone
tin and the posterior lobe secretes oxytocin. (GnRH), follicle stimulating hormone, and luteinising
hormone, which results in suppression of ovulation
Prolactin and menstruation. Therefore, frequent breastfeeding
Prolactin is necessary for the secretion of milk by the can help to delay a new pregnancy (see Session 8 on
cells of the alveoli. The level of prolactin in the blood Mother’s Health). Breastfeeding at night is important
increases markedly during pregnancy, and stimulates to ensure this effect.
the growth and development of the mammary tissue,
in preparation for the production of milk (19). How- Oxytocin
ever, milk is not secreted then, because progesterone Oxytocin makes the myoepithelial cells around the
and oestrogen, the hormones of pregnancy, block this alveoli contract. This makes the milk, which has col-
action of prolactin. After delivery, levels of progester- lected in the alveoli, flow along and fill the ducts (21)
one and oestrogen fall rapidly, prolactin is no longer (see Figure 5). Sometimes the milk is ejected in fine
blocked, and milk secretion begins. streams.
When a baby suckles, the level of prolactin in the
FIGuRe 5
blood increases, and stimulates production of milk oxytocin
by the alveoli (Figure 4). The prolactin level is highest
about 30 minutes after the beginning of the feed, so
its most important effect is to make milk for the next Sensory impulses
feed (20). During the first few weeks, the more a baby from nipples
suckles and stimulates the nipple, the more prolac- Oxytocin
tin is produced, and the more milk is produced. This in blood
effect is particularly important at the time when lac-
tation is becoming established. Although prolactin is
still necessary for milk production, after a few weeks Baby suckling
• Makes uterus
there is not a close relationship between the amount
contract
of prolactin and the amount of milk produced. How-
ever, if the mother stops breastfeeding, milk secretion
may stop too – then the milk will dry up. Works before or during a feed to make the milk flow
Faculty Guide to integration Breastfeeding in University Curricula
18
12 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
The oxytocin reflex is also sometimes called the “let- Psychological effects of oxytocin
down reflex” or the “milk ejection reflex”. Oxytocin Oxytocin also has important psychological effects,
is produced more quickly than prolactin. It makes the and is known to affect mothering behaviour in ani-
milk that is already in the breast flow for the current mals. In humans, oxytocin induces a state of calm,
feed, and helps the baby to get the milk easily. and reduces stress (22). It may enhance feelings of
Oxytocin starts working when a mother expects a affection between mother and child, and promote
feed as well as when the baby is suckling. The reflex bonding. Pleasant forms of touch stimulate the secre-
becomes conditioned to the mother’s sensations and tion of oxytocin, and also prolactin, and skin-to-skin
feelings, such as touching, smelling or seeing her baby, contact between mother and baby after delivery helps
or hearing her baby cry, or thinking lovingly about both breastfeeding and emotional bonding (23,24).
him or her. If a mother is in severe pain or emotion-
ally upset, the oxytocin reflex may become inhibited, 2.6 Feedback inhibitor of lactation
and her milk may suddenly stop flowing well. If she Milk production is also controlled in the breast by a
receives support, is helped to feel comfortable and lets substance called the feedback inhibitor of lactation, or
the baby continue to breastfeed, the milk will flow FIL (a polypeptide), which is present in breast milk
again. (25). Sometimes one breast stops making milk while
It is important to understand the oxytocin reflex, the other breast continues, for example if a baby suck-
because it explains why the mother and baby should les only on one side. This is because of the local con-
be kept together and why they should have skin-to- trol of milk production independently within each
skin contact. breast. If milk is not removed, the inhibitor collects
and stops the cells from secreting any more, helping
Oxytocin makes a mother’s uterus contract after to protect the breast from the harmful effects of being
delivery and helps to reduce bleeding. The contrac- too full. If breast milk is removed the inhibitor is also
tions can cause severe uterine pain when a baby suck- removed, and secretion resumes. If the baby cannot
les during the first few days. suckle, then milk must be removed by expression.
Signs of an active oxytocin reflex FIL enables the amount of milk produced to be deter-
mined by how much the baby takes, and therefore
Mothers may notice signs that show that the oxytocin
by how much the baby needs. This mechanism is
reflex is active:
particularly important for ongoing close regulation
K a tingling sensation in the breast before or during a after lactation is established. At this stage, prolactin
feed; is needed to enable milk secretion to take place, but it
does not control the amount of milk produced.
K milk flowing from her breasts when she thinks of
the baby or hears him crying;
2.7 Reflexes in the baby
K milk flowing from the other breast when the baby
The baby’s reflexes are important for appropriate
is suckling;
breastfeeding. The main reflexes are rooting, suckling
K milk flowing from the breast in streams if suckling and swallowing. When something touches a baby’s
is interrupted; lips or cheek, the baby turns to find the stimulus, and
opens his or her mouth, putting his or her tongue
K slow deep sucks and swallowing by the baby, which
down and forward. This is the rooting reflex and is
show that milk is flowing into his mouth;
present from about the 32nd week of pregnancy.
K uterine pain or a flow of blood from the uterus; When something touches a baby’s palate, he or she
K thirst during a feed. starts to suck it. This is the sucking reflex. When the
baby’s mouth fills with milk, he or she swallows. This
If one or more of these signs are present, the reflex is the swallowing reflex. Preterm infants can grasp
is working. However, if they are not present, it does the nipple from about 28 weeks gestational age, and
not mean that the reflex is not active. The signs may they can suckle and remove some milk from about
not be obvious, and the mother may not be aware of 31 weeks. Coordination of suckling, swallowing and
them. breathing appears between 32 and 35 weeks of preg-
nancy. Infants can only suckle for a short time at that
2. THe PHYsIoloGICAl BAsIs oF BReAsTFeedInG 19
13
age, but they can take supplementary feeds by cup. K the baby is suckling from the breast, not from the
A majority of infants can breastfeed fully at a gesta- nipple.
tional age of 36 weeks (26).
As the baby suckles, a wave passes along the tongue
When supporting a mother and baby to initiate and from front to back, pressing the teat against the hard
establish exclusive breastfeeding, it is important to palate, and pressing milk out of the sinuses into the
know about these reflexes, as their level of maturation baby’s mouth from where he or she swallows it. The
will guide whether an infant can breastfeed directly baby uses suction mainly to stretch out the breast tis-
or temporarily requires another feeding method. sue and to hold it in his or her mouth. The oxytocin
reflex makes the breast milk flow along the ducts,
2.8 How a baby attaches and suckles at the breast and the action of the baby’s tongue presses the milk
To stimulate the nipple and remove milk from the from the ducts into the baby’s mouth. When a baby
breast, and to ensure an adequate supply and a good is well attached his mouth and tongue do not rub or
flow of milk, a baby needs to be well attached so traumatise the skin of the nipple and areola. Suckling
that he or she can suckle effectively (27). Difficulties is comfortable and often pleasurable for the mother.
often occur because a baby does not take the breast She does not feel pain.
into his or her mouth properly, and so cannot suckle
effectively. Poor attachment
Figure 7 shows what happens in the mouth when a
FIGuRe 6 baby is not well attached at the breast.
Good attachment – inside the infant’s mouth
The points to notice are:
K only the nipple is in the baby’s mouth, not the
underlying breast tissue or ducts;
K the baby’s tongue is back inside his or her mouth,
and cannot reach the ducts to press on them.
Suckling with poor attachment may be uncomfort-
able or painful for the mother, and may damage the
skin of the nipple and areola, causing sore nipples and
fissures (or “cracks”). Poor attachment is the com-
monest and most important cause of sore nipples (see
Session 7.6), and may result in inefficient removal of
milk and apparent low supply.
FIGuRe 7
Good attachment Poor attachment – inside the infant’s mouth
Figure 6 shows how a baby takes the breast into his
or her mouth to suckle effectively. This baby is well
attached to the breast.
The points to notice are:
K much of the areola and the tissues underneath
it, including the larger ducts, are in the baby’s
mouth;
K the breast is stretched out to form a long ‘teat’, but
the nipple only forms about one third of the ‘teat’;
K the baby’s tongue is forward over the lower gums,
beneath the milk ducts (the baby’s tongue is in fact
cupped around the sides of the ‘teat’, but a drawing
cannot show this);
Faculty Guide to integration Breastfeeding in University Curricula
20
14 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
K the baby’s lower lip is curled outwards; Towards the end of a feed, suckling usually slows down,
with fewer deep suckles and longer pauses between
K the baby’s chin is touching or almost touching the them. This is the time when the volume of milk is
breast. less, but as it is fat-rich hindmilk, it is important for
These signs show that the baby is close to the breast, the feed to continue. When the baby is satisfied, he
and opening his or her mouth to take in plenty of or she usually releases the breast spontaneously. The
breast. The areola sign shows that the baby is taking nipple may look stretched out for a second or two, but
the breast and nipple from below, enabling the nipple it quickly returns to its resting form.
to touch the baby’s palate, and his or her tongue to
reach well underneath the breast tissue, and to press Signs of ineffective suckling
on the ducts. All four signs need to be present to show A baby who is poorly attached is likely to suckle inef-
that a baby is well attached. In addition, suckling fectively. He or she may suckle quickly all the time,
should be comfortable for the mother. without swallowing, and the cheeks may be drawn in
The signs of poor attachment are: as he or she suckles showing that milk is not flow-
ing well into the baby’s mouth. When the baby stops
K more of the areola is visible below the baby’s bot- feeding, the nipple may stay stretched out, and look
tom lip than above the top lip – or the amounts squashed from side to side, with a pressure line across
above and below are equal; the tip, showing that the nipple is being damaged by
K the baby’s mouth is not wide open; incorrect suction.
K the baby may pull away from the breast out of frus- FIGuRe 9
tration and refuse to feed; Baby well positioned at the breast
Position of the mother K He or she should be facing the breast. The nip-
The mother can be sitting or lying down (see Figure 9), ples usually point slightly downwards, so the baby
or standing, if she wishes. However, she needs to be should not be flat against the mother’s chest or
relaxed and comfortable, and without strain, particu- abdomen, but turned slightly on his or her back
larly of her back. If she is sitting, her back needs to be able to see the mother’s face.
supported, and she should be able to hold the baby at K The baby’s body should be close to the mother
her breast without leaning forward. which enables the baby to be close to the breast,
and to take a large mouthful.
Position of the baby
K His or her whole body should be supported. The
The baby can breastfeed in several different positions
baby may be supported on the bed or a pillow, or
in relation to the mother: across her chest and abdo-
the mother’s lap or arm. She should not support
men, under her arm (See Figure 16 in Session 6), or
only the baby’s head and neck. She should not
alongside her body.
grasp the baby’s bottom, as this can pull him or
Whatever the position of the mother, and the baby’s her too far out to the side, and make it difficult for
general position in relation to her, there are four key the baby to get his or her chin and tongue under
points about the position of the baby’s body that are the areola.
important to observe.
These points about positioning are especially impor-
K The baby’s body should be straight, not bent or tant for young infants during the first two months of
twisted. The baby’s head can be slightly extended life. (See also Feeding History Job Aid, 0–6 months,
at the neck, which helps his or her chin to be close in Session 5.)
in to the breast.
Faculty Guide to integration Breastfeeding in University Curricula
22
16 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
1
Faculty Guide to integration Breastfeeding in University Curricula
24
TakeTake
HomeHome messages
messages for anatomy
for anatomy and and physiology:
physiology:
Test
Test your
your knowledge:
knowledge: (see(see pre-test
pre-test andand post-test)
post-test)
Links
Links to teaching
to teaching videos:
videos:
http://www.mcfc.org.eg/Home/Gallery
http://www.mcfc.org.eg/Home/Gallery
http://www.mcfc.org.eg/courses/
http://www.mcfc.org.eg/courses/
http://mcfc.org.eg/arabic/Gallery,
http://mcfc.org.eg/arabic/Gallery,
http://www.unicef.org.eg/
http://www.unicef.org.eg/
http://www.breastcrawl.org
http://www.breastcrawl.org
25
Complementary
Continuing feeding
support for infant
SeSSIon 53
SeSSIon
and young child feeding
5.13.1 Support
Guiding
forPrinciples
mothers for
in the community Box9 1
Box
Complementary Feeding
Health workers do not always have the opportunity Guiding
Key pointsprinciples
of contactfortocomplementary
support optimalfeeding
to After
ensure6 that
months of age,successfully
mothers it becomes establish
increasingly diffi-
breast- of the breastfed child
cult for breastfed infants to meet their nutrient needs feeding practices
feeding. Mothers may give birth at home, or they may
from human milk alone. Furthermore most infants 1. Practise exclusive breastfeeding from birth to 6 months of
be discharged from a maternity facility within a day K during antenatal care
are developmentally ready for other foods at about 6 age, and introduce complementary foods at 6 months of
or so after delivery. Difficulties may arise in the first K Atage
the(180
timedays)
of childbirth and in thetoimmediate
months. In settings where environmental sanitation while continuing breastfeed.postpartum
few weeks with breastfeeding, and later on when com- period
is very poor, waiting until even later than 6 months to 2. Continue frequent, on-demand breastfeeding until 2 years
plementary foods are needed. Illness of infants and
introduce complementary foods might reduce expo-
young children is often associated with poor feed- K Inoftheagepostnatal period:
or beyond.
sure to food-borne diseases. However, because infants
ing. Families and friends are usually a mother’s main —3. for healthy
Practise term babies
responsive on day
feeding, 2–3, day
applying the5–7, and around
principles of
are beginning to actively explore their environment at
source of advice about feeding her children, but this 3–4 weeks care.
psychosocial
this age, they will be exposed to microbial contami-
advice is sometimes fraught by misconceptions. — for low-birth-weight babies more frequently: on day 2,
nants through soil and objects even if they are not 4. Practise good hygiene and proper food handling.
Mothers need continuingfoods.
given complementary support to maintain
Thus, 6 monthsexclu-
is the day 3, day 5–7, day 14, and day 28
5. start at 6 months of age with small amounts of food
siverecommended
and continued breastfeeding,
appropriate age attowhich
implement other
to introduce K At 6 weeks post partum for all mothers and babies
and increase the quantity as the child gets older, while
methods of infant foods
complementary feeding(1).when breastfeeding is not
K during immunization
maintaining frequentcontacts
breastfeeding.
possible, and to establish adequate complementary
During the period of complementary feeding, chil-
feeding when the child is 6 months of age and older K6.during
Gradually increase
well-baby foodand/or
clinics consistency andassessment
growth variety as the
visits
dren are at high risk of undernutrition (2). Comple-
(1).mentary
If a child becomes ill, the mother may require infant grows older, adapting to the infant’s requirements
foods are often of inadequate nutritional K during sick child visits and their follow-up
skilled and abilities.
quality, or theyfrom
support a health
are given worker
too early to late,
or too continue
in too
feeding her child. This support can be provided
small amounts, or not frequently enough. Premature by 7. Increase the number of times that the child is fed
trained personnel
cessation or low in the community,
frequency and in also
of breastfeeding variouscon- complementary foods as the child gets older.
other settings, such as a primary care facility
tributes to insufficient nutrient and energy intake or a pae-in
diatric department in a hospital. approach
8. Feedto promoting
a variety and foods
of nutrient-rich supporting infant
to ensure that all and
infants beyond 6 months of age. young child feeding has been shown to be effective in
nutrient needs are met.
There
The should
Guidingbeprinciples
no missed opportunities for
for complementary sup-of
feeding many settings (3).
porting feeding in any contact that a mother and 9. use fortified complementary foods or vitamin-mineral
the breastfed child, summarized in Box 1, set standards Box 9 summarizes
child supplements forkey pointsas of
the infant, contact that mothers
needed
for have with thelocally
developing health appropriate
system, whether it involves
feeding recom-
doctors, might have with a health worker who is knowledge-
mendations (3). They provide guidance on health
midwives, nurses or community desired 10. Increase fluid intake during illness, including more
workers. able and skilled to support her in practising appro-
feedingLay or peer counsellors
behaviours as well as onwho have theconsist-
the amount, skills frequent breastfeeding, and encourage the child to eat
andency,
knowledge to support optimaland infant and young priate infant and young child feeding. Mothers who
frequency, energy density nutrient content soft, favourite foods. After illness, give food more often
child feeding can also contribute to improved feeding are not breastfeeding also need help with infant feed-
of foods. The Guiding principles are explained in more than usual and encourage the child to eat more.
practices ing at these times, and many of the skills needed by
detail in(2).theCollectively,
paragraphs below. all these providers should
ensure a continuum of care from pregnancy through health workers to support them are similar.
theApostnatal
GuIdInG PRInCIPLe
period into 1. Practise exclusive breastfeeding
early childhood. When they but also in industrialized countries. According to the
from
help birth to 6they
a mother, months of age
should andtalk
also introduce
to other family 5.2
WHOInfant andstandards,
growth young child feeding
children counselling
who are exclusive-
complementary
members, showingfoods at 6 months
respect for theirof ideas,
age (180
and days)
help- Infant and young
ly breastfed have achild
morefeeding counselling
rapid growth in the isfirst
the6
ingwhile
themcontinuing to breastfeed
to understand advice on optimal feeding. process
monthsbyofwhich a health
life than other worker can support moth-
infants (4).
In Exclusive
addition, breastfeeding
they can share information and create ers and babies to implement good feeding practices
for 6 months confers several By the age of 6 months, a baby has usually at least
awareness and help them overcome difficulties. Details of infant
benefits to the infant and the of
about the importance appropriate
mother. Chiefinfant
among doubled his or her birth weight, and is becoming
andthese
young child feedingeffect
through other channels, and young child feeding counselling depend on the
is the protective against gastrointestinal more active. Exclusive breastfeeding is no longer suf-
forinfections,
example, by involving school child’s
ficientage and all
theenergy
mother’s
and circumstances. Gener-
which is observed notchildren
only in or exten-
developing to meet nutrient needs by itself,
sion workers from other sectors. This multi-pronged ally, a health worker should:
Faculty Guide to integration Breastfeeding in University Curricula
26
38 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
Skills for support of IYCF
K Refer the mother and child if needed Building confidence and giving support
K Help the mother with feeding difficulties or poor K Accept what a mother thinks and feels.
practices K Recognize and praise what a mother and infant are doing
K Support good feeding practices right.
K Counsel the mother on her own health, nutrition K Give practical help.
and family planning. K Give a little, relevant information.
Follow-up K use simple language.
K Make one or two suggestions (e.g. small “do-able”
5.3 using good communication and support skills actions), not commands
If a health care worker is to effectively counsel a moth-
er or other caregiver, he or she should have good com-
munication skills. The same skills are useful in many be able to follow, and which may even make her
situations, for example for family planning, and also unwilling to talk to you again.
in ordinary life. They may be described in slightly
different ways and with different details in different Listening and learning skills
publications, but the principles are the same. The Using helpful non-verbal communication. Non-
tools described here include the basic skills useful in verbal communication means how you communicate
relation to infant and young child feeding. There are a other than by speaking. Helpful non-verbal com-
number of similar tools that can be used for the same munication shows that the health worker respects
purpose. the mother and is interested in her. It includes: keep-
ing your head about level with the mother’s, and not
towering over her; making eye contact, nodding and
smiling; making sure that there are no barriers, such
The sections that follow provide concrete guidance on infant as a table or conspicuous papers, between you and the
and complementary feeding counselling. They are written in a mother; making sure that you do not seem to be in a
direct style and often address the reader with ‘you’ to make it hurry; touching her or the baby in a culturally appro-
more interesting and easier to absorb the content. priate way.
Asking open questions. “Open questions” often
start with “how”, “when”, “who”, “what”, “why”. To
There are two groups of skills (see Box 10):
answer them it is necessary to give some information,
K listening and learning skills help you to encour- so they encourage a person to talk, and conversation
age a mother to talk about her situation and how becomes easier. The opposite are “closed questions”,
she feels in her own way, and they help you to pay which usually start with “Do you?”, “Are you”, “Is
attention to what she is saying; he?”, “Has she?”. A person can answer them with a
“yes” or “no”, thus giving little information. Open
K building confidence and giving support skills help
questions can also be more general, for example “Tell
you to give a mother information and suggest what
me more about…”.
she might do in her situation, so that she can decide
for herself what to do. Supporting a mother is more Using responses and gestures that show interest.
useful than giving direct advice which she may not Such responses include “Oh dear”, “Really?”, “Go
5. ConTInuInG suPPoRT FoR InFAnT And YounG CHIld FeedInG 27
39
on…” or “Eeeeh”. Gestures such as nodding and smil- of advice or has been struggling with her baby, this
ing are also responses that show interest. Showing kind of practical help may be the best way to show
interest encourages a mother to say more. that you understand, and she may be more receptive
to new information and suggestions. Helping with
Reflecting back what the mother says. Reflecting is
her breastfeeding technique is also practical help, but
a very helpful way to show that you are listening and
of a different kind as it involves giving her informa-
to encourage a mother to say more. It is best to reflect
tion too. She may not be ready for that at first.
back using slightly different words from the mother,
not to repeat exactly what she has said. You may only Giving a little relevant information. After you have
need to use one or two of the important words that listened to a mother or caregiver, think about her sit-
she used to show that you have heard her. uation and decide what information is most relevant
and useful at the time. You should avoid telling her
Empathizing. Showing that you understand how she
too much, because she may become confused and for-
feels lets the woman know that you understand her
get what is most important. Sometimes the most use-
feelings from her point of view, using phrases such as
ful information is a clear explanation of what she has
“you are worried”, “you were very upset” or “that is
noticed, for example the baby’s behaviour, or changes
hard for you”. You can also empathize with good feel-
in her breasts; or what to expect, for example how
ings, for example, “you must feel pleased”.
breast milk “comes in”, or when and why the infant
Avoiding words that sound judging. These are words needs foods in addition to breast milk. Helping her
such as “right”, “wrong”, “good”, “well”, “badly”, to understand the process is better than immediately
“properly”, “enough”. For example, the care provider telling her what to do.
should not say “Are you feeding your baby properly?
Using simple language. It is important to give infor-
Do you have enough milk?” This can make a mother
mation in a way that is easy for a person to under-
feel doubtful, and that she may be doing something
stand, using simple, everyday words.
wrong. It is better to ask “How are you feeding your
baby? How about your breast milk?” Sometimes ask- Making suggestions, not commands. If you tell a
ing “why” may sound judging, for example “Why did mother what to do, she may not be able to do it, but it
you give a bottle last night?” It is better to ask “What can be difficult for her to disagree with you. She may
made you give a bottle?” just say “yes” and not come back. Giving a suggestion
allows her to discuss whether or not she can follow
Confidence and support skills it. You can make other suggestions, encourage her to
Accepting what a mother thinks and feels. Accept- think of more practical alternatives and help her to
ing means not disagreeing with a mother or caregiver, decide what to do. This is particularly important in
but at the same time not agreeing with an incorrect the case of infant and young child feeding, when there
idea. Disagreeing with someone can make her feel often are different options.
criticised, and reduce her confidence and willing-
ness to communicate with you. Accepting involves 5.4 Assessing the situation
responding in a neutral way. Later, you can give the 5.4.1 Assessing the child’s growth
correct information.
Assessing a child’s growth provides important infor-
Recognizing and praising what a mother and baby mation on the adequacy of the child’s nutritional sta-
are doing right. Health workers are trained to look tus and health. There are several measures to assess
for problems and may only see what is wrong and growth, including weight-for-age, weight-for-height,
then try to correct it. Recognizing and praising a and height-for-age. In the past, many countries used
mother’s good practices helps to reinforce them and weight-for-age to assess both children’s growth and
build her confidence. You can also praise what a baby their present nutritional status. National growth curves
does, such as growing and developing well. were based on weight-for-age. With the availability of
the WHO growth standards (4), countries may revisit
Giving practical help. Helping a mother or caregiver
their growth charts and introduce weight-for-height as
in other ways than talking, often quite simply, such
the standard for measuring nutritional status, and pro-
as giving her a drink of water, making her comfort-
vide training for health workers. It is recommended to
able in bed or helping her to wash are examples of
use separate standards for boys and girls.
practical help. When a mother has had a great deal
Faculty Guide to integration Breastfeeding in University Curricula
28
40 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
Skills for support of IYCF
When counselling on infant and young child feed- indicator can help identify children who are stunted
ing, it is important to understand growth charts. If (or short) due to prolonged undernutrition or repeat-
growth is not recorded correctly, and charts are not ed illness. Children who are tall for their age can also
interpreted accurately, incorrect information can be be identified, but tallness is rarely a problem unless
given to a mother, leading to worry or loss of confi- it is excessive and may reflect uncommon endocrine
dence. The following sections explain briefly the dif- disorders. Acute malnutrition does not affect height.
ferent measures.
Mid-upper arm circumference
Weight-for-age Another useful way to assess a child’s present nutri-
Weight-for-age reflects body weight relative to the tional status is to measure the mid-upper arm cir-
child’s age on a given day. A series of weights can tell cumference (MUAC) (5). MUAC below 115 mm is an
you whether or not a child’s weight is increasing over accurate indicator of severe malnutrition in children
time, so it is a useful indicator of growth. This indica- 6–59 months of age (6). MUAC should be measured
tor is used to assess whether a child is underweight in all children who have a very low weight-for-age (see
or severely underweight, but it is not used to clas- Figure 14). MUAC can also be used for rapidly screen-
sify a child as overweight or obese. Because weight is ing all children in a community for severe malnutri-
relatively easily measured, this indicator is commonly tion. Management of severe malnutrition is discussed
used, but it cannot be relied upon in situations where in Session 6.
the child’s age cannot be accurately determined. Also,
it cannot distinguish between acute malnutrition and FIGuRe 14
chronic low energy and nutrient intake. Examples of Measuring mid-upper arm circumference
weight-for-age charts for boys and girls are included
in Annex 2.
Weight-for-length/height1
Weight-for-length/height reflects body weight in pro- deciding whether a child is growing adequately or not
portion to attained growth in length or height. This The curved lines printed on the growth charts will
indicator is especially useful in situations where chil- help you interpret the plotted points that represent a
dren’s ages are unknown (e.g. refugee settlements). child’s growth status. The line labelled “0” on each
Weight-for-length/height charts help identify chil- chart represents the median, which is, generally speak-
dren with low weight-for-height who may be wasted ing, the average. The other curved lines are z-score
or severely wasted. These charts also help identify lines,2 which indicate distance from the average.
children with high weight-for-length/height who may
be at risk of becoming overweight or obese. However, Z-score lines on the growth charts are numbered pos-
assessing weight-for-height requires two measure- itively (1, 2, 3) or negatively (−1, −2, −3). In general,
ments – of weight and height – and this may not be a plotted point that is far from the median in either
feasible in all settings.
1
Length of children less than 2 years of age is measured lying
length/height-for-age down, while standing height is measured for children 2 years of
Length/height-for-age reflects attained growth in age or older.
TABle 4
Identifying growth problems from plotted points
Z-sCoRe GRoWTH IndICAToRs
Box 13
Breastfeed observation Job Aid
Mother’s name......................................................................................................................... date..............................................................
Baby’s name............................................................................................................................. Baby’s age....................................................
Recognize if the child has any signs of severe illness decide on management. Figure 15 summarizes three
that require immediate referral: categories of actions that may be required, namely:
Refer urgently; Help with difficulties and poor prac-
K unconscious or lethargic
tices and refer, if necessary; Support for good feeding
K severely malnourished
practices.
K not able to eat or drink
K not able to breastfeed even after help with attach-
ment 5.5.1 Refer urgently
K copious vomiting after all feeds. Refer the infant or young child urgently to hospital if
he or she:
Also check for conditions that can interfere with
breastfeeding: K is unconscious or lethargic, and thus may be very
ill;
K blocked nose (makes suckling and breathing
difficult) K is severely malnourished;
K jaundice (baby may be sleepy and suckle less) K is not able to drink or eat anything;
K thrush (Candida) (baby may take short feeds only,
or may refuse to feed) K is not able to breastfeed even after help with
K cleft lip or palate (makes attachment difficult and attachment;
baby may have low milk intake) K vomits copiously, which may be both a sign of
K tongue tie (makes attachment difficult, may cause serious illness and of danger because he or she
sore nipples and low milk intake). will not be able to take medications or fluids for
rehydration.
Assessing the health of the mother
There may be a need to give one or more treatments
During feeding counselling it is also important to in the clinic before the infant or child leaves for
enquire about the mother’s own health status, her hospital:
mental health, her social situation and her employ-
ment. These are all factors that will affect her abil- K Oral or intramuscular antibiotic for possible severe
ity to care for her young child. Important topics to infection;
address are listed in the Feeding History Job Aid (Box K Rectal or intramuscular antimalarial for severe
11), and include: malaria;
K Observe the state of her nutrition, general health K If a child is still able to breastfeed, particularly if
and breast health as part of the observation of a malnourished, ask the mother to continue offer-
breastfeed. ing the breast while being referred. Otherwise give
K Try to learn her ideas about another pregnancy, and sugar water to prevent low blood sugar (hypogly-
if she is adequately informed about family plan- caemia) by mixing 2 teaspoons (10 g) of sugar with
ning and has access to appropriate counselling. half a glass (100 ml) of water;
K If a mother seems to have serious clinical or mental K Ensure warmth, especially for newborn babies and
health problems or if she is taking regular medica- malnourished children.
tion, make an additional physical examination and
refer as necessary for specialized treatment (see 5.5.2 Help with difficulties and poor practices
Session 8). Breastfeeding
K If not recorded on medical records, ask the moth- Most feeding difficulties and poor practices can be
er if she has been tested for HIV. If not, encour- managed with outpatient care or care in the commu-
age her to do so (depending on current national nity.
guidance).
You may be concerned about poor practices, even
though the mother is not aware of particular difficul-
5.5 Managing problems and supporting good ties. You may need to help a mother to position and
feeding practices attach her baby at the breast to establish optimal and
The results of the assessment are used to classify the effective breastfeeding (see Session 4.5) and discuss
mother and baby according to their situation and to with her how to improve her breastfeeding pattern.
Faculty Guide to integration Breastfeeding in University Curricula
34
46 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
Skills for support of IYCF
FIGuRe 15
Assessing and classifying infant and young child feeding
A mother may ask for help with a difficulty that she Complementary feeding
herself has become aware of. Session 7 describes the Sometimes a child over 6 months of age may be mal-
most common feeding difficulties and summarizes nourished or growing poorly, or may not be eating
key steps in their management. well. Mothers and other caregivers may not complain
Non-urgent referral may be necessary if more spe- of difficulties with complementary feeding, but their
cialized help is needed than is available at your level. practices are not optimal. In either situation, you
Refer children with: should recognise the need to counsel them about
improving the way in which they feed the child.
K poor growth that continues despite health centre
or community care; Use the Food Intake Reference Tool (Table 5) to find
out if the child is fed according to recommendations.
K breastfeeding difficulties that do not respond to
Decide what information the mother needs, and what
the usual management;
she is able to do to improve the child’s feeding.
K abnormalities including cleft lip and palate, tongue
The first column contains questions about what the
tie, Down syndrome, cerebral palsy.
child has eaten in the previous 24 hours, to help you
learn how the child is fed. The second column shows
the ideal practice and the third column suggests a key
5. ConTInuInG suPPoRT FoR InFAnT And YounG CHIld FeedInG 35
47
TABle 5
Food Intake Reference Tool, children 6–23 months
FeedInG PRACTICe IdeAl PRACTICe keY MessAGe To use In CounsellInG THe MoTHeR
Growth curve rising? Growth follows the reference curve explain child’s growth curve and praise good
growth
Child received breast milk? Frequently on demand, day and night Breastfeeding for 2 years or longer helps a child
to develop and grow strong and healthy
Child ate sufficient number of meals and snacks K Child 6–8 months: 2–3 meals plus 1–2 snacks A growing child needs to eat often, several times
yesterday, for his or her age? if hungry a day according to age
K Child 9–23 months: 3–4 meals plus 1–2 snacks
if hungry
quantity of food eaten at main meal yesterday K Child 6–8 months: start with a few spoons and A growing child needs increasing amounts of food
appropriate for child’s age? gradually increase to approx. ½ cup at each meal
K Child 9–11 months: approx. ½ cup at each meal
K Child 12–23 months: approx. ¾ to 1 cup at
each meal
How many meals of a thick consistency did the K Child 6–8 months: 2–3 meals Foods that are thick enough to stay on the spoon
child eat yesterday? (use consistency photos K Child 9–23 months: 3–4 meals give more energy to the child
as needed)
Child ate an animal-source food yesterday Animal-source foods should be eaten daily Animal-source foods are especially good for
(meat/fish/offal/bird/eggs)? children to help them grow strong and lively
Child ate a dairy product yesterday? Give diary products daily Milk, cheese and yogurt are especially good
for children
Child ate pulses, nuts or seeds yesterday? If meat is not eaten, pulses or nuts should be eaten Peas, beans, lentils and nuts help children to grow
daily – with vitamin-rich fruits to help absorb iron strong and lively, especially if eaten with fruit
Child ate red or orange vegetable or fruit, or a dark A dark green vegetable or red or orange vegetable dark green leaves and red or orange coloured
green vegetable yesterday? or fruit should be eaten daily fruits and vegetables help the child to have
healthy eyes and fewer infections
small amount of oil added to child’s food A little oil or fat should be added to a meal each oil gives a child more energy, but is only needed
yesterday? day in small amounts
Mother assisted the child at meal times? Mother assists and encourages the child to eat, A child needs to learn to eat: encourage and give
but does not force help responsively and with lots of patience
Child had his or her own bowl, or ate from Child should have his or her own bowl of food If a child has his/her own bowl, it makes it easier
family pot? to see how much the child has eaten
Child took any vitamin or mineral supplements? Vitamin and mineral supplements may be needed explain how to use vitamin and mineral
if child’s needs are not met by food intake supplements if they are needed
Child ill or recovering from an illness? Continue to feed during illness and recovery encourage the child to drink and eat during illness,
and provide extra food after illness to help the
child recover quickly
Faculty Guide to integration Breastfeeding in University Curricula
36
48 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
Skills for support of IYCF
Skills and knowledge of counselling are Weight loss is when the direction of baby’s
essential to improving perinatal and feeding growth curve (serial measurements) is
practices and managing feeding or lactation directed downwards or crosses the lower
difficulties. curves (centiles) this indicates serious
Active listening helps mothers to express infection as TB or AIDs.
their fears and worries by using open ended Catch–up growth occurs when the baby’s
questions, reflecting back and empathy. curve is directed upwards and crosses the
Building confidence skills helps mothers upper lines (centiles), this indicates baby is
to reach a solution to her problem that is recovering and is climbing up to reach his
suitable for her needs. or her own target centile or if obese climb
Effective counselling involves using down into his or her growth curve (intended
acceptance, empathy, praising, informing in by their genetic make-up).
a positive way and explaining by giving Identify and manage a baby who is losing
options or suggestions and not commands. weight or having a breastfeeding difficulty
Counseling skills are used during by taking a full perinatal and breastfeeding,
examination, assessment of a breastfeed history, assessing breastfeeding technique
and growth assessment and to change any and practices, nutritional status and intake,
misconception or misbelief. in addition to examination of the mother
Growth in the first year of life is assessed and child for health problems.
by weight-for-age using the WHO growth Refer the infant or young child urgently to
standards (used for breastfed babies) to hospital if s/he is unconscious or lethargic,
show the mother how her baby is gaining severely malnourished; not able to drink or eat
weight on her milk. anything; not able to breastfeed even after help
Mid-upper arm circumference (MUAC) with attachment; and/or vomits copiously.
below 115 mm is an accurate indicator of
severe malnutrition in children 6–59
months of age.
Weight-for-length/height growth charts
help identify children with low weight-for-
height who may be wasted or severely
wasted.
Length/height-for-age growth charts help
identify children who are stunted when the
plotted point is below the −2 z-score curve
or identify obesity when plotted points is
above the +2 z-score lines.
Growth monitoring is the optimal way to
assess growth through plotting serial
measurements on the weight-for age or
length-for-age growth charts i.e., as long as
the baby is following his/her target centile
for growth then he or she is healthy.
Growth faltering is when the baby is not
gaining weight and his growth curve is flat,
this happens due to illness or inadequate
transfer of milk or nutrition intake.
1
39
Management and support of infant
SeSSIon 4
feeding in maternity facilities
1
References to the Code generally imply also subsequent relevant
Health Assembly resolutions.
Faculty Guide to integration Breastfeeding in University Curricula
40
30 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
A STeP 1: Have a written breastfeeding policy that is Antenatal preparation of the breasts for breastfeed-
routinely communicated to all health care staff ing is not helpful. Exercises to stretch flat or inverted
nipples, and devices worn over the nipples during
A hospital policy and related guidelines should cover
pregnancy, are not effective in increasing breastfeed-
all aspects of management outlined by the Ten Steps,
ing success (9). Providing skilled support to help the
and all staff should be fully informed about the policy.
baby to attach soon after delivery is more effective.
To be accredited as baby-friendly, a hospital is required
to avoid all promotion of breast-milk substitutes
(BMS) and related products, bottles and teats, and not
4.4 early contact
to accept free or low-cost supplies or to give out sam- The first hour of a baby’s life is of great importance for
ples of those products (see Session 9.1.2 on the Code). the initiation and continuation of breastfeeding, and
to establish the emotional bond between mother and
A STeP 2: Train all health care staff in skills necessary to baby. Delays in initiation of breastfeeding after the
implement this policy first hour increase the risk of neonatal mortality, in
particular neonatal deaths due to infections (10,11).
All health care staff with responsibility for mothers
and babies should be trained to implement the policy, A STeP 4: Help mothers initiate breastfeeding within
which includes being able to help mothers to initiate one half hour of birth
and establish breastfeeding, and to overcome difficul-
ties. Training courses have been developed by WHO A baby should be delivered straight onto the mother’s
and UNICEF for this purpose (7,8). abdomen and chest, before delivery of the placenta
or any other procedures, unless there are medical
4.3 Antenatal preparation or obstetric complications that make it impossible
(12,13). The baby must be dried immediately to pre-
Preparation of mothers before they give birth is fun-
vent heat loss and then placed in skin-to-skin contact
damental to the success of the BFHI.
with the mother, usually in an upright position. Skin-
to-skin contact means that both the mother’s upper
A STeP 3: Inform all pregnant women about the
body and her baby should be naked, with the baby’s
benefits and management of breastfeeding
upper body between the mother’s breasts. They should
Women need information about: be covered together to keep them warm. Skin-to-skin
K the benefits of breastfeeding and the risks of artifi- contact should start immediately after delivery or
cial or mixed feeding; within at least half an hour; and should continue for
as long as possible, but for at least one hour uninter-
K optimal practices, such as early skin-to-skin con- rupted (12). Mothers usually find the experience a
tact, exclusive breastfeeding, rooming-in, starting pleasure and emotionally meaningful.
to breastfeed soon after delivery, and why colos-
trum is important; Skin-to-skin contact is the best way to initiate breast-
feeding. A few babies want to suckle immediately.
K what to expect, including how the milk “comes in”, Most babies remain quiet for some time, and only
and how a baby suckles; start to show signs of readiness to feed after 20–30
K what they will need to do: skin-to-skin contact, minutes or more; some take over an hour (14). Car-
putting the baby to the breast, and appropriate pat- egivers should ensure that the baby is comfortably
terns of feeding. positioned between the mother’s breasts, but they
should not try to attach the baby to the mother’s
Some questions are usefully discussed in groups,
breast; the baby can do this in his or her own time.
while for others individual counselling is more appro-
Eventually a baby becomes more alert, and may start
priate. Opportunities for both are needed antenatally
raising his or her head, looking around, making
and postnatally, when mothers visit a health facility,
mouthing movements, sucking his or her hands, or
or during contacts with a community health worker.
massaging the breast with them. Some babies move
At group sessions, women can raise doubts and ask
towards and may find the areola and nipple by them-
questions, and discuss them together. Women who
selves, guided by their sense of smell (15). The mother
have concerns that they do not want to share with a
can help move her baby closer to the areola and nip-
group, or who have had difficult experiences before,
ple to start suckling. Many babies attach well at this
need to discuss them privately.
time, which helps them to learn to suckle effectively
4. MAnAGeMenT And suPPoRT oF InFAnT FeedInG In MATeRnITY FACIlITIes 41
31
Box 7 FIGuRe 12
Back massage to stimulate the oxytocin reflex before
How to express breast milk by hand expressing breast milk
The mother should:
K Have a clean, dry, wide-necked container for the expressed
breast milk;
K Wash her hands thoroughly;
K sit or stand comfortably and hold the container under her
nipple and areola;
K Put her thumb on top of her breast and her first finger
on the underside of her breast so that they are opposite each
other about 4 cms from the tip of the nipple;
K Compress and release her breast between her finger and
thumb a few times. If milk does not appear, re-position her
thumb and finger a little closer or further away from the
nipple and compress and release a number of times as before.
This should not hurt – if it hurts, the technique is wrong. At
first no milk may come, but after compressing a few times,
milk starts to drip out. It may flow in streams if the oxytocin A health worker or counsellor should explain to the
reflex is active; mother the basic principles:
K Compress and release all the way around her breast, with K Express both breasts each time.
her finger and thumb the same distance from the nipple; K Express the milk into a cup, glass, jug or jar that
K express each breast until the milk drips slowly; has been thoroughly washed with water and soap.
K Repeat expressing from each breast 5 to 6 times; K Store EBM in a glass with a cover indicating time
and date.
K stop expressing when milk drips slowly from the start of
compression, and does not flow; K Keep EBM at room temperature for 8 hours or in
a refrigerator for 24 to 48 hours. If she has a deep
K Avoid rubbing or sliding her fingers along the skin; freeze she can store it for 3 months (21).
K Avoid squeezing or pinching the nipple itself.
stimulating the oxytocin reflex
Before the mother expresses her milk, she should
weight or premature may be separated from the stimulate her oxytocin reflex, to help the milk flow.
mother in a special care baby unit (see Session 6.1 She may do this herself by lightly massaging her
on low-birth-weight babies). breasts, or stimulating her nipples, and at the same
time thinking about the baby, watching him or her
K If a baby is able to take oral or enteral feeds, breast
if nearby, or looking at a photograph of him or her.
milk is usually the best feed to give.
She can also ask a helper to massage up and down her
K If a baby cannot take oral feeds, then it is helpful back on either side of her spine between her shoulder
for the mother to express her milk to build up and blades (see Figure 12).
maintain the supply, for when the baby is able to
start breastfeeding. Expressed breast milk (EBM) 4.6 Creating a supportive environment for
can be frozen and stored until the baby needs it breastfeeding
(21). In some facilities that are able to operate ade- Maternity facilities should ensure that their practices
quate standards for milk banking, it may be pos- are supportive, so that babies stay close to their moth-
sible to donate milk for other infants (22). ers for demand feeding, and that babies are not giv-
en unnecessary supplements, fed by bottle, or given
dummies (pacifiers).
4. MAnAGeMenT And suPPoRT oF InFAnT FeedInG In MATeRnITY FACIlITIes 43
33
A STeP 6: Give newborn infants no food or drink other mother should offer the other breast, but the baby
than breast milk unless medically indicated may or may not want to take more. She can start on
the other breast at the next feed. In the first few days,
Foods and drinks given to a newborn baby before
babies may want to feed very often, and this is ben-
breastfeeding has started are called prelacteal feeds.
eficial because it stimulates milk production. The
Giving these feeds increases the risk of illnesses such
health worker should make sure that the baby is well
as diarrhoea and other infections and allergies, par-
attached and suckling effectively, and help the mother
ticularly if they are given before the baby has had
to understand that the baby will feed less often when
colostrum. Prelacteal feeds satisfy a baby’s hunger
breastfeeding is established.
and thirst, making him or her less interested in feed-
ing at the breast, so there is less stimulation of breast A STeP 9: Give no artificial teats or pacifiers (also called
milk production. If a bottle is used, it may inter- dummies or soothers) to breastfeeding infants
fere with the baby learning to suckle at the breast.
Since prelacteal feeds can interfere with establish- Feeding a baby from a bottle with an artificial teat
ing breastfeeding, they should not be given without may make it more difficult for the baby to learn to
an acceptable medical reason (23). (See Annex 1 for attach well at the breast and may make it more dif-
acceptable medical reasons for use of breast-milk ficult to establish breastfeeding satisfactorily (26). If
substitutes). an infant cannot feed from the breast, then the safest
alternative is to feed from a cup (see Figure 13 and Box
A STeP 7: Practice rooming-in – allow mothers and 8). Even low-birth-weight and premature babies can
infants to remain together – 24 hours a day cup feed. The reasons to feed with a cup include:
Babies should be allowed to stay in the same room K Cups are easier to clean, and can be cleaned with
as their mother, either in a cot beside her bed or in soap and water, if boiling is not possible.
the bed with her, 24 hours a day (24). They should be K Feeding from a cup does not interfere with the
separated only when strictly necessary, for example baby learning to suckle at the breast.
for a medical or surgical procedure. A cot should be
beside the mother’s bed, where she can easily see and K A cup cannot be left for the baby to feed him- or
reach her baby, not at the end of the bed, where it is herself. Someone has to hold the baby and give him
more difficult. Studies have shown that babies cry less some of the contact that he needs.
and mothers sleep as much when they are together as K Cup feeding is generally easier and better than
when the infant is in a separate room (8). Separating spoon feeding: spoon feeding takes longer and
infants from their mothers may be associated with requires an extra hand, and sometimes a baby does
long-term psychological trauma (25). not get enough milk by spoon.
Rooming-in is essential to enable a mother to breast-
feed her baby on demand and for her to learn the cues
such as wakefulness, rooting and mouthing, which FIGuRe 13
Feeding a baby by cup
show that her baby is ready for a feed. It is better to
feed the baby in response to these cues than to wait
until the baby is crying.
53
Continuing support for infant
SeSSIon
SeSSIon
and young child feeding
3.1 Guiding Principles for Box 1
Complementary Feeding
5.1 Support for mothers in the community Guiding
Box 9 principles for complementary feeding
After 6 months of age, it becomes increasingly diffi-
Health workers do not always of the breastfed child
cult for breastfed infants to meethave
theirthe opportunity
nutrient needs Key points of contact to support optimal
to ensure that mothers successfully
from human milk alone. Furthermore most infants establish breast- 1.feeding
Practisepractices
exclusive breastfeeding from birth to 6 months of
feeding.
are Mothers mayready
developmentally give birth at home,
for other foodsoratthey
about may
6 age, and introduce complementary foods at 6 months of
be discharged from a maternity facility within a day K age
during
(180antenatal carecontinuing to breastfeed.
days) while
months. In settings where environmental sanitation
isorvery
so after
poor,delivery.
waiting Difficulties maythan
until even later arise6 in the first
months to 2.K Continue
At the time of childbirth and in the immediate postpartum
frequent, on-demand breastfeeding until 2 years
few weeks with breastfeeding, and later on when com- period
introduce complementary foods might reduce expo- of age or beyond.
plementary foods are needed. Illness of infants and
sure to food-borne diseases. However, because infants K In the postnatal period:
young children is often associated with poor feed- 3. Practise responsive feeding, applying the principles of
are beginning to actively explore their environment at
ing. Families and friends are usually a mother’s main —psychosocial
for healthy term
care. babies on day 2–3, day 5–7, and around
this age, they will be exposed to microbial contami-
source of advice about feeding her children, but this 3–4 weeks
nants through soil and objects even if they are not 4. Practise good hygiene and proper food handling.
advice is sometimes fraught by misconceptions. — for low-birth-weight babies more frequently: on day 2,
given complementary foods. Thus, 6 months is the
Mothers need continuing 5. start at day
day 3, 6 months of age
5–7, day withday
14, and small
28 amounts of food
recommended appropriatesupport to maintain
age at which exclu-
to introduce
and increase the quantity as the child gets older, while
sive and continued
complementary foods (1). breastfeeding, to implement other K At 6 weeks post partum for all mothers and babies
methods of infant feeding when breastfeeding is not maintaining frequent breastfeeding.
During the period of complementary feeding, chil- K during immunization contacts
possible, and to establish adequate complementary 6. Gradually increase food consistency and variety as the
dren arewhen
at hightherisk of undernutrition (2). and
Comple- K infant
duringgrows
well-baby
feeding child is 6 months of age older older,clinics and/or
adapting growth
to the assessment
infant’s visits
requirements
mentary foods are often of inadequate
(1). If a child becomes ill, the mother may require nutritional
quality, or they are given too early or tootolate, in too K and abilities.
during sick child visits and their follow-up
skilled support from a health worker continue
small amounts, or not frequently enough.
feeding her child. This support can be provided by Premature 7. Increase the number of times that the child is fed
cessation or low frequency
trained personnel of breastfeeding
in the community, and inalso con-
various complementary foods as the child gets older.
tributes to insufficient
other settings, such as anutrient
primaryandcareenergy
facilityintake in
or a pae- 8. Feed a variety of nutrient-rich foods to ensure that all
infants beyond 6 months of
diatric department in a hospital. age. approach to promoting and supporting infant and
nutrient needs are met.
young child feeding has been shown to be effective in
The
There Guiding
shouldprinciples
be no missedfor complementary
opportunitiesfeeding of
for sup- many settings
9. use fortified(3).
complementary foods or vitamin-mineral
the breastfed child, summarized in Box
porting feeding in any contact that a mother and 1, set standards
for
childdeveloping
have with thelocally
healthappropriate
system, whetherfeedingit involves
recom- Box 9 supplements
summarizes for the
keyinfant,
pointsas needed
of contact that mothers
mendations (3). Theynurses
doctors, midwives, provideorguidance
community on desired
health might have fluid
10. Increase withintake
a health
during worker who ismore
illness, including knowledge-
feeding behaviours as well as on the amount,
workers. Lay or peer counsellors who have the skills consist- able and skilled
frequent to support
breastfeeding, her in practising
and encourage the child to eatappro-
ency, frequency,to
and knowledge energy
supportdensity
optimalandinfant
nutrientandcontent
young priatesoft,
infant andfoods.
favourite young
Afterchild
illness,feeding. Mothers
give food more often who
of foods.
child The Guiding
feeding can alsoprinciples
contributeare toexplained
improvedin more
feeding are not breastfeeding also need help with
than usual and encourage the child to eat more. infant feed-
detail in the
practices (2).paragraphs
Collectively,below.
all these providers should ing at these times, and many of the skills needed by
ensure a continuum of care from pregnancy through health workers to support them are similar.
Athe
GuIdInG PRInCIPLe
postnatal period1.into
Practise
earlyexclusive
childhood. breastfeeding
When they but also in industrialized countries. According to the
from birth to 6 months of age and introduce
help a mother, they should also talk to other family 5.2 Infant
WHO growthand young child
standards, feeding
children whocounselling
are exclusive-
complementary
members, showing foodsrespect
at 6 months of age
for their (180 and
ideas, days)help- ly breastfed
Infant and have
younga more
child rapid growth
feeding in the first
counselling 6
is the
while continuing
ing them to breastfeed
to understand advice on optimal feeding. months
process ofbylife thana other
which healthinfants
worker(4).
can support moth-
In addition, they can share information and create ers and babies to implement good feeding practices
Exclusive breastfeeding for 6 months confers several By the age of 6 months, a baby has usually at least
awareness about the importance of appropriate infant and help them overcome difficulties. Details of infant
benefits to the infant and the mother. Chief among doubled his or her birth weight, and is becoming
and young child feeding through other channels, and young child feeding counselling depend on the
these is the protective effect against gastrointestinal more active. Exclusive breastfeeding is no longer suf-
for example, by involving school children or exten- child’s age and the mother’s circumstances. Gener-
infections, which is observed not only in developing ficient to meet all energy and nutrient needs by itself,
sion workers from other sectors. This multi-pronged ally, a health worker should:
Faculty Guide to integration Breastfeeding in University Curricula
48
20 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
and complementary foods should be introduced to have revealed that a casual style of feeding predomi-
make up the difference. At about 6 months of age, an nates in some populations. Young children are left to
infant is also developmentally ready for other foods feed themselves, and encouragement to eat is rarely
(5). The digestive system is mature enough to digest observed. In such settings, a more active style of feed-
the starch, protein and fat in a non-milk diet. Very ing can improve dietary intake. The term “responsive
young infants push foods out with their tongue, but feeding” (see Box 2) is used to describe caregiving that
by between 6 and 9 months infants can receive and applies the principles of psychosocial care.
hold semi-solid food in their mouths more easily.
A child should have his or her own plate or bowl so
that the caregiver knows if the child is getting enough
A GuIdInG PRInCIPLe 2. Continue frequent on-demand
food. A utensil such as a spoon, or just a clean hand,
breastfeeding until 2 years of age or beyond
may be used to feed a child, depending on the culture.
Breastfeeding should continue with complementary The utensil needs to be appropriate for the child’s age.
feeding up to 2 years of age or beyond, and it should Many communities use a small spoon when a child
be on demand, as often as the child wants. starts taking solids. Later a larger spoon or a fork may
Breast milk can provide one half or more of a child’s be used.
energy needs between 6 and 12 months of age, and Whether breastfeeds or complementary foods are giv-
one third of energy needs and other high quality en first at any meal has not been shown to matter. A
nutrients between 12 and 24 months (6). Breast milk mother can decide according to her convenience, and
continues to provide higher quality nutrients than the child’s demands.
complementary foods, and also protective factors.
Breast milk is a critical source of energy and nutrients A GuIdInG PRInCIPLe 4. Practise good hygiene and
during illness (7), and reduces mortality among chil- proper food handling
dren who are malnourished (8, 9). In addition, as dis-
Microbial contamination of complementary foods is
cussed in Session 1, breastfeeding reduces the risk of a
a major cause of diarrhoeal disease, which is partic-
number of acute and chronic diseases. Children tend
ularly common in children 6 to 12 months old (12).
to breastfeed less often when complementary foods
Safe preparation and storage of complementary foods
are introduced, so breastfeeding needs to be actively
can prevent contamination and reduce the risk of
encouraged to sustain breast-milk intake.
diarrhoea. The use of bottles with teats to feed liquids
is more likely to result in transmission of infection
A GuIdInG PRInCIPLe 3. Practise responsive feeding
than the use of cups, and should be avoided (13).
applying the principles of psychosocial care
All utensils, such as cups, bowls and spoons, used
Optimal complementary feeding depends not only
for an infant or young child’s food should be washed
on what is fed but also on how, when, where and
thoroughly. Eating by hand is common in many cul-
by whom a child is fed (10,11). Behavioural studies
tures, and children may be given solid pieces of food
to hold and chew on, sometimes called “finger foods”.
Box 2
It is important for both the caregiver’s and the child’s
Responsive feeding hands to be washed thoroughly before eating.
K Feed infants directly and assist older children when they Bacteria multiply rapidly in hot weather, and more
feed themselves. Feed slowly and patiently, and encourage slowly if food is refrigerated. Larger numbers of bacte-
children to eat, but do not force them. ria produced in hot weather increase the risk of illness
K If children refuse many foods, experiment with different (14). When food cannot be refrigerated it should be
food combinations, tastes, textures and methods of eaten soon after it has been prepared (no more than 2
encouragement. hours), before bacteria have time to multiply.
K Minimize distractions during meals if the child loses Basic recommendations for the preparation of safe
interest easily. foods (15) are summarized in Box 3.
200
0
0–2 m 3–5 m 6–8 m 9–11 m 12–23 m
Age (months)
1
The age ranges should be interpreted as follows: a child 6–8
months is 6 months or older (≥ 180 days) but is not yet 9 months
old (< 270 days).
Faculty Guide to integration Breastfeeding in University Curricula
50
22 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
TABle 1
Practical guidance on the quality, frequency and amount of food to offer children 6–23 months of age
who are breastfed on demand
AGe eneRGY needed PeR dAY In TexTuRe FRequenCY AMounT oF Food An AVeRAGe
AddITIon To BReAsT MIlk CHIld WIll usuAllY eAT AT
eACH MeAla
6–8 months 200 kcal per day start with thick porridge, 2–3 meals per day start with 2–3 tablespoonfuls
well mashed foods per feed, increasing gradually
depending on the child’s appetite, to ½ of a 250 ml cup
Continue with mashed 1–2 snacks may be offered
family foods
9–11 months 300 kcal per day Finely chopped or mashed 3–4 meals per day ½ of a 250 ml cup/bowl
foods, and foods that baby
can pick up depending on the child’s appetite,
1–2 snacks may be offered
12–23 months 550 kcal per day Family foods, chopped or 3–4 meals per day ¾ to full 250 ml cup/bowl
mashed if necessary
depending on the child’s appetite,
1–2 snacks may be offered
Further information
The amounts of food included in the table are recommended when the energy density of the meals is about 0.8 to 1.0 kcal/g.
If the energy density of the meals is about 0.6 kcal/g, the mother should increase the energy density of the meal (adding special foods) or increase the amount of food per meal. For
example:
— for 6 to 8 months, increase gradually to two thirds cup
— for 9 to 11 months, give three quarters cup
— for 12 to 23 months, give a full cup.
The table should be adapted based on the energy content of local complementary foods.
The mother or caregiver should feed the child using the principles of responsive feeding, recognizing the signs of hunger and satiety. These signs should guide the amount of food
given at each meal and the need for snacks.
a
If baby is not breastfed, give in addition: 1–2 cups of milk per day, and 1–2 extra meals per day (18).
A GuIdInG PRInCIPLe 6. Gradually increase food to give more kcal and to include a variety of nutri-
consistency and variety as the infant grows older, ent-rich ingredients including animal-source foods.
adapting to the infant’s requirements and abilities There is evidence of a critical window for introducing
‘lumpy’ foods: if these are delayed beyond 10 months
The most suitable consistency for an infant’s or
of age, it may increase the risk of feeding difficulties
young child’s food depends on age and neuromus-
later on. Although it may save time to continue feed-
cular development (19). Beginning at 6 months, an
ing semi-solid foods, for optimal child development it
infant can eat pureed, mashed or semi-solid foods. By
is important to gradually increase the solidity of food
8 months most infants can also eat finger foods. By
with age.
12 months, most children can eat the same types of
foods as consumed by the rest of the family. However, A GuIdInG PRInCIPLe 7. Increase the number of times
they need nutrient-rich food, as explained in Guiding that the child is fed complementary foods as the child
principle 8, and foods that can cause choking, such as gets older
whole peanuts, should be avoided.
As a child gets older and needs a larger total quantity
A complementary food should be thick enough so of food each day, the food needs to be divided into a
that it stays on a spoon and does not drip off. Gen- larger number of meals.
erally, foods that are thicker or more solid are more
energy- and nutrient-dense than thin, watery or soft The number of meals that an infant or young child
foods. When a child eats thick, solid foods, it is easier needs in a day depends on:
3. CoMPleMenTARY FeedInG 51
23
K how much energy the child needs to cover the ener- FIGuRe 11
gy gap. The more food a child needs each day, the Gaps to be filled by complementary foods for a breastfed
more meals are needed to ensure that he or she gets child 12–23 months
enough. 100 Gap
K the amount that a child can eat at one meal. This
vitamin A, but not of iron. A child needs the solid young children can consume a variety of foods from
part of these foods, not just the watery sauce. the age of six months, including cow milk, eggs, pea-
nuts, fish and shellfish (18).
K Dairy products, such as milk, cheese and yoghurt,
are useful sources of calcium, protein, energy and
A GuIdInG PRInCIPLe 9. use fortified complementary
B vitamins.
foods or vitamin-mineral supplements for the infant as
K Pulses – peas, beans, lentils, peanuts, and soybeans needed
are good sources of protein, and some iron. Eat-
Unfortified complementary foods that are predomi-
ing sources of vitamin C (for example, tomatoes,
nantly plant-based generally provide insufficient
citrus and other fruits, and green leafy vegetables)
amounts of certain key nutrients (particularly iron,
at the same time helps iron absorption.
zinc and vitamin B6) to meet recommended nutrient
K Orange-coloured fruits and vegetables such as car- intakes during complementary feeding. Inclusion of
rot, pumpkin, mango and papaya, and dark-green animal-source foods can meet the gap in some cases,
leaves such as spinach, are rich in carotene, from but this increases cost and may not be practical for
which vitamin A is made, and also vitamin C. the lowest-income groups. Furthermore, the amounts
of animal-source foods that can feasibly be consumed
K Fats and oils are concentrated sources of energy,
by infants (e.g. at 6–12 months) are generally insuf-
and of certain essential fats that children need to
ficient to meet the gap in iron. The difficulty in meet-
grow.
ing the needs for these nutrients is not unique to
Vegetarian (plant-based) complementary foods do not developing countries. Average iron intakes in infants
by themselves provide enough iron and zinc to meet in industrialized countries would fall well short of
all the needs of an infant or young child aged 6–23 recommended intake if iron-fortified products were
months. Animal-source foods that contain enough not widely available. Therefore, in settings where lit-
iron and zinc are needed in addition. Alternatively, tle or no animal-source foods are available to many
fortified foods or micronutrient supplements can fill families, iron-fortified complementary foods or foods
some of the critical nutrient gaps. fortified at the point of consumption with a multinu-
Fats, including oils, are important because they trient powder or lipid-based nutrient supplement may
increase the energy density of foods, and make them be necessary.
taste better. Fat also helps the absorption of vitamin
A GuIdInG PRInCIPLe 10. Increase fluid intake during
A and other fat-soluble vitamins. Some fats, espe-
illness, including more frequent breastfeeding, and
cially soy and rapeseed oil, also provide essential fatty
encourage the child to eat soft, favourite foods. After
acids. Fat should comprise 30–45% of the total ener-
illness, give food more often than usual and encourage
gy provided by breast milk and complementary foods
the child to eat more
together. Fat should not provide more than this pro-
portion, or the child will not eat enough of the foods During an illness, the need for fluid often increases,
that contain protein and other important nutrients, so a child should be offered and encouraged to take
such as iron and zinc. more, and breastfeeding on demand should continue.
A child’s appetite for food often decreases, while the
Sugar is a concentrated source of energy, but it has
desire to breastfeed increases, and breast milk may
no other nutrients. It can damage children’s teeth,
become the main source of both fluid and nutrients.
and lead to overweight and obesity. Sugar and sug-
ary drinks, such as soda, should be avoided because A child should also be encouraged to eat some com-
they decrease the child’s appetite for more nutritious plementary food to maintain nutrient intake and
foods. Tea and coffee contain compounds that can enhance recovery (20). Intake is usually better if the
interfere with iron absorption and are not recom- child is offered his or her favourite foods, and if the
mended for young children. foods are soft and appetizing. The amount eaten at
any one time is likely to be less than usual, so the
Concerns about potential allergic effects are a com-
caregiver may need to give more frequent, smaller
mon reason for families to restrict certain foods in
meals.
the diets of infants and young children. However,
there are no controlled studies that show that restric- When the infant or young child is recovering, and his
tive diets have an allergy-preventing effect. Therefore, or her appetite improves, the caregiver should offer
3. CoMPleMenTARY FeedInG 53
25
TABle 3
Appropriate foods for complementary feeding
WHAT FoodS To GIve And WHy HoW To GIve THe FoodS
BReAsT MIlk: continues to provide energy and high quality nutrients Infants 6–11 months
up to 23 months
K Continue breastfeeding
sTAPle Foods: provide energy, some protein (cereals only) and
K Give adequate servings of:
vitamins
K examples: cereals (rice, wheat, maize, millet, quinoa), roots — Thick porridge made out of maize, cassava, millet; add milk, soy, ground
(cassava, yam and potatoes) and starchy fruits (plantain and nuts or sugar
breadfruit)
— Mixtures of pureed foods made out of matoke, potatoes, cassava, posho
AnIMAl-souRCe Foods: provide high quality protein, haem iron, zinc (maize or millet) or rice: mix with fish, beans or pounded groundnuts;
and vitamins add green vegetables
K examples: liver, red meat, chicken, fish, eggs (not good source of
K Give nutritious snacks: egg, banana, bread, papaya, avocado, mango, other
iron)
fruits, yogurt, milk and puddings made with milk, biscuits or crackers, bread or
MIlk PRoduCTs: provide protein, energy, most vitamins (especially chapati with butter, margarine, groundnut paste or honey, bean cakes, cooked
vitamin A and folate), calcium potatoes
K examples: milk, cheese, yogurt and curds
Children 12–23 months
GReen leAFY And oRAnGe-ColouRed VeGeTABles: provide vitamins
A, C, folate K Continue breastfeeding
K examples: spinach, broccoli, chard, carrots, pumpkins, sweet
K Give adequate servings of:
potatoes
— Mixtures of mashed or finely cut family foods made out of matoke,
Pulses: provide protein (of medium quality), energy, iron (not well
potatoes, cassava, posho (maize or millet) or rice; mix with fish or beans
absorbed)
or pounded groundnuts; add green vegetables
K examples: chickpeas, lentils, cowpeas, black-eyed peas, kidney
beans, lima beans — Thick porridge made out of maize, cassava, millet; add milk, soy, ground
nuts or sugar
oIls And FATs: provide energy and essential fatty acids
K examples: oils (preferably soy or rapeseed oil), margarine, butter K Give nutritious snacks: egg, banana, bread, papaya, avocado, mango, other
or lard fruits, yogurt, milk and puddings made with milk, biscuits or crackers, bread or
chapati with butter, margarine, groundnut paste or honey, bean cakes, cooked
seeds: provide energy
potatoes
K examples: groundnut paste or other nut pastes, soaked or
germinated seeds such as pumpkin, sunflower, melon, sesame
ReMIndeR:
Foods rich in iron
K liver (any type), organ meat, flesh of animals (especially red meat), flesh of birds (especially dark meat), foods fortified with iron
Foods rich in Vitamin A
K liver (any type), red palm oil, egg yolk, orange coloured fruits and vegetables, dark green vegetables
Foods rich in zinc
K liver (any type), organ meat, food prepared with blood, flesh of animals, birds and fish, shell fish, egg yolk
Foods rich in calcium
K Milk or milk products, small fish with bones
Foods rich in Vitamin C
K Fresh fruits, tomatoes, peppers (green, red, yellow), green leaves and vegetables
Key: 1=c, 2= d, 3= c
Practice exercises:
Exercise 1: In the following case scenarios use your counseling skills of
“accepting” and “praising”, “informing” and giving one or two suggestions not
commands.
1
Faculty Guide to integration Breastfeeding in University Curricula
56 Example: Agnes is in tears. Her baby has completed 6 developed a rash on his buttocks. The rash
months but is refusing to eat vegetables and she is looks like a nappy rash.
worried. You examine him and see he is growing well Case 3: A mother is giving her nine-month-
and is healthy: Answers: Accepting: I see you are old baby fizzy drinks. She is worried that he
worried about your baby refusing to eat; Praising: It’s is not eating his meals well. He is growing
well at the moment. She offers him three
great that you have tried feeding him, your baby seems meals and one snack per day.
prefer your breastmilk; Informing: Babies at this age
Case 4: A 15-month-old child is
refuse to feed at first but with time they accept, Giving
breastfeeding and having thin porridge and
Suggestions: have you tried mixing your milk with the sometimes tea and bread. He has not
food you offer, the odour of your milk may help him to gained weight for six months, and is thin
accept the food. and miserable.
Case 2: Susan is crying. Since starting Case 5: A nine-month-old baby and his
complementary feeds her baby has mother have come to see you. Here is the
growth chart on weight for age of the baby.
Exercise 2: Put a circle round the letter which corresponds to the information
which is most relevant for her.
To answer: Mothers 1-4 Information
1. Mother with a seven-month-old baby a (b) c d a. Children need extra water at this age –
about 4-5 cups in a hot climate
2. Mother with a 15-month-old baby who is a b (c) d b. Children who start complementary
getting two meals per day feeding at six completed months of age
grow well
3. Mother with a 12-month-old baby who a b c (d) c. Growing children of this age need
thinks that the baby is too old to breastfeed three to four meals per day, plus one to
any longer two snacks if hungry, in addition to milk.
2
57
Appropriate feeding in exceptionally
SeSSIon 6
difficult circumstances
One of the operational targets of the Global Strategy maintenance, hygienic cord and skin care, and early
for Infant and Young Child Feeding addresses specifi- detection and treatment of infections can substan-
cally the needs of mothers and children in exception- tially reduce excess mortality (2,3).
ally difficult circumstances. These circumstances
This section deals with feeding low-birth-weight
include babies who are low birth weight, and infants
babies. It summarizes what, how, when and how
and young children who are malnourished, who are
much to feed to low-birth-weight babies. Table 6 sum-
living in emergency situations, or who are born to
marizes the information that is discussed in more
mothers living with HIV.
detail in other parts of this Session.
Nevertheless, experience from developed and devel- K expressed breast milk (EBM) (from his or her own
oping countries has shown that appropriate care of mother);
LBW infants, including their feeding, temperature K donor breast milk (4);
TABle 6
Feeding low-birth-weight babies
FeedInG loW-BIRTH-WeIGHT BABIes
> 36 Weeks GesTATIonAl AGe 32–36 Weeks GesTATIonAl AGe < 32 Weeks GesTATIonAl AGe
WHAT breast milk breast milk, expressed or suckled from expressed breast milk
the breast
HoW breastfeeding cup, spoon, paladai (in addition to feeding at the breast) intra-gastric tube
WHen K start within one hour of birth K start within one hour of birth or as K start 12–24 hours after birth
K breastfeed at least every 3 hours soon as the baby is clinically stable K feed every 1–2 hours
K feed every 2–3 hours
HoW MuCH feed on demand see Tables 7 and 8 see Tables 7 and 8
Faculty Guide to integration Breastfeeding in University Curricula
58
52 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
some breast milk directly into the baby’s mouth gives babies less than < 1500g may need to receive some of
the baby the taste of milk and stimulates the sucking these requirements as intravenous fluids, as they may
and swallowing reflexes (see instructions in Box 15). not tolerate full enteral feeds.
Thereafter, offer the full amount of feed by cup (Table
The quantities in the table are calculated according to
8). The baby may not finish all the cup feed as he or
the baby’s need for:
she may have already had some milk from the breast.
Reduce the cup feeds slowly if the baby starts suckling K 60 ml/kg on day 1, increasing by 10 or 20 ml per
well. Bottle feeding should be avoided, as it may inter- day over 7 days up to 160 ml/kg/day.
fere with the baby learning to breastfeed. K 8 feeds in 24 hours.
Babies less than 32 weeks gestational age usually need If a baby has more than 8 feeds in 24 hours, the amount
to be fed by gastric tube. They should not receive any per feed must be reduced accordingly, to achieve the
enteral feeds in the first 12–24 hours. Table 7 shows the same total volume in 24 hours.
quantity of milk that a LBW baby fed by gastric tube
needs each day and Table 8 shows how much is needed
Cup feeds
at each feed. The quantity needs to be exact. However,
A baby who is cup fed (see Figure 17) needs to be offered 5
TABle 7
ml extra at each feed. This slightly larger amount allows
Recommended fluid intake for LBW infants for spillage with cup feeding. It is important to keep a
record of the 24-hour total and ensure that it meets the
dAY oF lIFe FluId RequIReMenTs (ml/kg/day)
required total ml/kg per day for the baby’s weight.
2000–2500 g 1500–2000 g 1000–1500 g
day 1 60 60 60 FIGuRe 17
day 2 80 75 70 Cup feeding a low-birth-weight baby
day 3 100 90 80
day 4 120 115 90
day 5 140 130 110
day 6 150 145 130
day 7 160+ 160 150*
* if the infant is on intravenous fluids, do not increase above 140 ml/kg/day
TABle 8
Recommended feed volumes for LBW infants
dAY oF lIFe Feed VoluMes (ml)
day 1 17 12 6
day 2 22 16 7
quantities after 7 days
If the baby is still having EBM by cup or gastric tube
day 3 27 20 8
after 7 days, increase the quantity given by 20 ml/kg
day 4 32 24 9 each day until the baby is receiving 180 ml/kg per day.
day 5 37 28 11 As the baby begins to breastfeed more frequently, the
day 6 40 32 13 amount of EBM given by gastric tube or cup may be
gradually reduced.
day 7 42 35 16
If the baby is cup feeding, add 5 ml per feed to allow for spillage and variability of
The baby’s weight needs to be monitored. Babies
infant’s appetite. weighing over 1500 grams at birth can be expected
* For infants with birth weight <1250 g who do not show signs of feeding
to regain their original birth weight after 1–2 weeks,
readiness, start with small 1–2 ml feeds every 1–2 hours and give the rest of the while for babies with a birth weight below 1500
fluid requirement as intravenous fluids. grams, this may take 2–3 weeks. Thereafter, average
Faculty Guide to integration Breastfeeding in University Curricula
60
54 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
discharge
A LBW baby can be discharged from hospital when
he or she is:
K Breastfeeding effectively or the mother is confident
using an alternative feeding method;
K Maintaining his or her own temperature between
36.5 °C and 37.5 °C for at least 3 consecutive days;
K Gaining weight, at least 15 g/kg for 3 consecutive
days; and
K The mother is confident in her ability to care for
her baby.
Before discharging a mother and her LBW baby from
a close relationship with her baby, and increases her
hospital, a discussion should take place with her on
confidence.
how she can be supported at home and in the com-
munity. If a mother lives a long distance from the hos-
Management
pital and it is difficult for her to return for a follow-up
visit, her baby should not be discharged until he or The mother keeps her baby in prolonged skin-to-skin
she fully meets the criteria. If possible, the mother contact day and night, in an upright position between
should stay with her baby to establish breastfeeding her breasts (Figure 18). The baby is supported in this
before discharge. She should be given the name and position by the mother’s clothes, or by cloths tied
contact details of any local breastfeeding support around her chest. The baby’s head is left free so that
groups, whether health facility or community based. he or she can breathe, and the face can be seen. The
baby wears a nappy for cleanliness and a cap to keep
6.1.3 Follow up of LBW babies the head warm.
The baby should have follow-up visits at least once KMC has been shown to keep the baby warm, to
2–5 days after discharge, and at least weekly until stabilize his or her breathing and heart rate, and to
fully breastfeeding and weighing more than 2.5 kg. reduce the risk of infection. It helps the mother to ini-
Ideally these should be home visits by a community tiate breastfeeding earlier, and the baby to gain weight
breastfeeding counsellor, or visits by the mother to faster. Most routine care can be carried out while
a nearby health facility. Further follow-up can then the baby remains in skin-to-skin contact. When the
continue monthly as for a term baby. mother has to attend to her own needs, skin-to-skin
contact can be continued by someone else, for exam-
6.1.4 Kangaroo mother care ple by the father or a grandparent, or the baby can be
wrapped and put into a cot or on a bed until KMC can
Kangaroo mother care (KMC) is a way in which
be continued.
a mother can give her LBW or small baby benefits
similar to those provided by an incubator (5). The It is not essential for a baby to be able to coordinate
mother has more involvement in the baby’s care; and sucking and swallowing to be eligible for KMC. Other
she has extended skin-to-skin contact, which helps methods of feeding can be used until the baby is able
both breastfeeding and bonding, probably because it to breastfeed. Close contact with the mother means
stimulates the release of prolactin and oxytocin from that the baby is kept very near to her breasts, and can
her pituitary gland. KMC helps a mother to develop easily smell and lick milk expressed onto her nipple.
6. APPRoPRIATe FeedInG In exCePTIonAllY dIFFICulT CIRCuMsTAnCes 61
55
He or she can be given breast milk by direct expres- food (RUTF), in addition to breastfeeding and com-
sion into his mouth until able to attach well. plementary feeding, with weekly or bi-weekly follow-
up by a trained health care provider (6).
KMC should be continued for as long as necessary,
which is usually until the baby is able to maintain his The first form of RUTF was invented in the late 1990s.
or her temperature, is breathing without difficulty Products qualifying to be called RUTF are energy-
and can breastfeed without the need for alternative dense mineral- and vitamin-enriched foods equiva-
methods of feeding. It is usually the baby who indi- lent in formulation to Formula 100 (F100), which is
cates that he or she is ready and ‘wants to get out’. recommended by WHO for the treatment of malnu-
If the mother lives near the hospital or health facil- trition in in-patient settings. However, recent studies
ity the baby may be discharged breastfeeding and/ have shown that RUTF promotes faster recovery from
or using an alternative feeding method, such as cup severe acute malnutrition than standard F100. It has
feeding with the mother’s EBM. little available water (low water activity), which means
that it is microbiologically safe, will keep for several
The mother and her baby should be monitored regu-
months in simple packaging and can be made easily
larly. In the first week after discharge, the baby should
using low-tech production methods. RUTF is eaten
be weighed daily, if possible, and a health care worker
uncooked, and is an ideal vehicle to deliver many
should discuss any difficulties with the mother, pro-
micronutrients that might otherwise be broken down
viding her with support and encouragement. Moni-
by cooking. RUTF is useful to treat severe malnutri-
toring should continue until the baby weighs more
tion without complications in communities with lim-
than 2.5 kg. When the baby becomes less tolerant of
ited access to appropriate local diets for nutritional
the position, the mother may reduce the time in KMC
rehabilitation. As full replacement of the normal diet,
and then stop altogether over about a week. Once the
150–220 kcal/kg per day should be provided until the
baby has stopped KMC, monthly follow-up should be
child has gained 15% to 20% of his or her weight.
continued to monitor feeding, growth and develop-
ment until the baby is several months old. However, if a child has severe malnutrition with an
associated complication, most commonly an infection,
6.2 Severe malnutrition the child should be admitted to hospital (7,8). Infec-
Severe malnutrition in children 6–59 months of age tions are the most common complications, and can
is defined as weight-for-height less than -3 z-scores, manifest themselves by lack of appetite only. The ini-
or the presence of oedema of both feet, or a mid-upper tial management should include prevention or treat-
arm circumference (MUAC) of less than 115 mm (see ment of hypoglycaemia, hypothermia, dehydration
Session 5.4). Children with a MUAC <115 mm should and infection, and regular feeding and monitoring.
be treated for severe malnutrition regardless of their A special therapeutic formula diet, F75, is required.
weight-for-height. In the initial phase, a child’s metabolic state is frag-
ile, and feeding must be cautious, with frequent small
There are no defined cut-off points for MUAC for
feeds of low osmolarity and low in lactose. If a child
infants less than 6 months. In this age group, visible
is breastfed, this should be continued while ensur-
severe wasting and oedema, in conjunction with dif-
ing that adequate amounts of F75 are given. When a
ficulties in breastfeeding, are criteria for identifying
child improves and his or her appetite is returning, he
infants who are severely malnourished.
or she should be given a special diet adapted for catch-
Severely malnourished children are in need of special up growth. A child aged more than 6 months can be
care both during the early rehabilitation phase and offered RUTF. If intake is satisfactory, treatment can
over the longer term. They are at risk of life-threat- continue at home, with weekly or bi-weekly follow-up.
ening complications such as hypoglycaemia, hypo-
For infants aged less than 6 months, continued fre-
thermia, serious infections, dehydration, and severe
quent breastfeeding is important, in addition to any
electrolyte disturbances.
necessary therapeutic feeds. If breastfeeding has
Malnourished infants and young children should been discontinued or if breast-milk production has
be assessed clinically to look for associated compli- decreased, it can often be re-established by use of the
cations. Above the age of 6 months, if the general supplementary suckling technique with therapeutic
condition of the child is good, and in particular if feeding (see Session 6.4). Relactation by supplementary
the appetite is maintained, the child can be treated suckling, or by allowing the baby to suckle as often as
at home with provision of a ready-to-use therapeutic he or she is willing while cup feeding, is an important
Faculty Guide to integration Breastfeeding in University Curricula
62
56 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
part of management (9). Malnutrition often has its Supportive general conditions
origin in inadequate or disrupted breastfeeding. A number of general conditions can greatly benefit
infant and young child feeding, and staff who are
6.3 Infants and young children living in managing an emergency response should endeavour
emergency situations to establish them:
Why infant and young child feeding is exceptionally Recognition of vulnerable groups: Pregnant women,
vulnerable in emergencies infants under 6 months, and young children between
In emergencies infants and young children are more 6 and 24 months should be counted and registered
likely than older children or adults to become ill and separately. Newborn infants should be registered
die from malnutrition and disease (10). Optimal feed- immediately, and the household made eligible for an
ing is often disrupted because of lack of basic resourc- additional ration for the breastfeeding mother and
es such as shelter and water, and physical and mental food suitable for complementary feeding of young
stress on families. Breastfeeding may stop because children, when appropriate.
mothers are ill, traumatised, or separated from their
Adequate food, water and nutrients: Mothers should
babies, and yet it is particularly valuable in emergency
receive an adequate general ration, and sufficient drink-
situations (11). Artificial feeding is more dangerous
ing water. If the full general ration is not available, food
because of poor hygiene, lack of clean water and fuel,
and micronutrient supplements should be provided as
and unreliability of supplies. There may be no food
a priority for pregnant and lactating women.
suitable for complementary feeding, or facilities for
preparing feeds and storing food safely. Shelter and privacy: Shelters for families should be
provided in preference to communal shelters. Breast-
Breast-milk substitutes including infant formula and
feeding women need private areas (as culturally
feeding bottles may be sent to emergency situations
appropriate) at distribution or registration points,
in inappropriate amounts by donors who believe
and rest areas in transit sites.
that they are urgently required, but who are poorly
informed about the real needs. Without proper con- Community support: Women need support from their
trols, these supplies are often given freely to families family and communities, so the population should be
who do not need them, and stocks run out before helped to settle in familiar groups.
more arrive for those who might have a genuine need Reduction of demands on time: People spend hours
(12). The result is inappropriate and unsafe use of queuing for relief commodities such as food, water,
breast-milk substitutes, and a dangerous and unnec- and fuel, which is difficult for mothers caring for
essary increase in early cessation of breastfeeding. young children. Priority access for mothers and other
Babies may be given unsuitable foods, such as dried caregivers enables them to give children more time.
skimmed milk, because nothing else is available. Sanitary washing facilities should be set up near the
area assigned to women with infants.
Management in emergencies
The principles and recommendations for feeding Specific help with feeding in emergencies
infants and young children in emergency situations In addition to supportive general conditions, mothers
are exactly the same as for infants in ordinary cir- need help with infant and young child feeding specifi-
cumstances. For the majority, the emphasis should be cally. An emergency response should aim to include
on protecting, promoting and supporting breastfeed- the following forms of support:
ing, and ensuring timely, safe and appropriate com-
plementary feeding. Most malnourished mothers can Baby-friendly maternity care: The Ten Steps for Suc-
continue to breastfeed while they are being fed and cessful Breastfeeding (see Session 4.1, Box 5) should be
treated themselves. A minority of infants will need to implemented at both health facilities and for home
be fed on breast-milk substitutes, short term or long deliveries. Skilled support from trained breastfeeding
term. This may be necessary if their mothers are dead counsellors and community groups is needed antena-
or absent, or too ill or traumatised to breastfeed, and tally and in the first weeks after delivery.
no wet-nurses are available; or for infants who have Availability of suitable complementary foods: In addi-
been artificially fed prior to the emergency or whose tion to breast milk, infants and young children from
HIV-positive mothers choose not to breastfeed. 6 months onwards need complementary foods that
6. APPRoPRIATe FeedInG In exCePTIonAllY dIFFICulT CIRCuMsTAnCes 63
57
are hygienically prepared and easy to eat and digest. K If a mother is very ill (temporary use may be all
Blended foods, especially if they are fortified with that is necessary).
essential nutrients, can be useful for feeding older
K If a mother is relactating (temporary use).
infants and young children. However, their provi-
sion should not interfere with promoting the use of K If a mother tests HIV-positive and chooses to use a
local ingredients and other donated commodities breast-milk substitute (see Session 6.5).
for preparing suitable complementary foods (see Ses- K If a mother rejects the infant, for example after
sion 3). The use of feeding bottles should continue to rape (temporary use may be all that is necessary).
be discouraged.
K If an infant (born before the emergency) is already
Skilled help in the community to: dependent on artificial feeding (use BMS to at least
K teach mothers how to breastfeed and continue to six months or use temporarily until relactation is
support them until their infant reaches 24 months; achieved).
K teach mothers about adequate complementary For an infant identified according to agreed criteria
feeding from 6 months of age using available as in need of BMS, supplies should be provided for
ingredients; as long as the infant needs them. Caregivers should
receive guidance about hygienic and appropriate
K support mothers to practise responsive feeding;
feeding with BMS (10). Every effort should be made
K identify and help mothers with difficulties, and to prevent “spill over” of artificial feeding to mothers
follow them up at home if possible; and babies who do not need it, by teaching the care-
giver privately to prepare feeds, and by taking care not
K monitor the growth of infants and young children,
to display containers of BMS publicly.
and counsel the mother accordingly.
Adequate health services to: 6.4 Relactation
K support breastfeeding and complementary feed- The re-establishment of breastfeeding is an important
ing; management option in emergency situations, and for
infants who are malnourished or ill (9).
K help mothers to express their milk and cup feed
any infant who is too small or sick to breastfeed;
Motivation and support
K search actively for malnourished infants and young
Most women can relactate any number of years after
children so that their condition can be assessed
their last child, but it is easier for women who stopped
and treated;
breastfeeding recently, or if the infant still suckles
K admit mothers of sick or malnourished infants to sometimes. A woman needs to be highly motivated,
the health or nutrition rehabilitation clinic with and well supported by health care workers. Continu-
their children; ing support can be provided by community health
workers, mother support groups, women friends,
K help mothers of malnourished infants to relactate
older women and traditional birth attendants.
and achieve adequate breastfeeding before dis-
charge from care, in addition to necessary thera-
peutic feeding. Stimulation of the breasts
Stimulation of the breasts is essential, preferably by
Controlled use of breast-milk substitutes (BMS): Breast-
the infant suckling as often and for as long as possible.
milk substitutes should be procured and distributed
Many infants who have breastfed before are willing to
as part of the regular inventory of foods and medi-
suckle, even if there is not much milk being produced
cines, in quantities only as needed (see also UNHCR
currently. Suckling causes release of prolactin, which
policy (13)). There should be clear criteria for their
stimulates growth of alveoli in the breast and the pro-
use, agreed by the different agencies that are involved
duction of breast milk. The mother and infant must
for each particular situation (14), but usually includ-
stay together all the time. Skin-to-skin contact, or
ing the following:
kangaroo mother care (see Session 6.1.4) are helpful. If
K If a child’s mother has died or is unavoidably the infant is willing to suckle, the mother should put
absent. him or her to the breast frequently, at least 8–12 times
every 24 hours, ensuring that attachment is good. If
Faculty Guide to integration Breastfeeding in University Curricula
64
58 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
the infant is not willing to suckle, she can start the FIGuRe 19
relactation process by stimulating her breasts with using supplementary suckling to help a mother to relactate
gentle breast massage and then with 20–30 minutes
of hand expression 8–12 times a day.
needs to be balanced with the need to support opti- K Exclusive breastfeeding is recommended for HIV-
mal nutrition of all infants through exclusive and infected mothers for the first 6 months of life unless
continued breastfeeding and adequate complemen- replacement feeding is acceptable, feasible, afford-
tary feeding. able, sustainable and safe for them and their infants
before that time (see Box 16 for definitions).
Mother-to-child transmission of HIV K When replacement feeding is acceptable, feasi-
In 2007, about 2.5 million children under 15 years ble, affordable, sustainable and safe, avoidance
of age were living with HIV, and an estimated 420 of all breastfeeding by HIV-infected mothers is
000 children were newly infected. The predomi- recommended.
nant source of HIV infection in young children is
K All HIV-exposed infants should receive regu-
MTCT. The virus may be transmitted during preg-
lar follow-up care and periodic re-assessment of
nancy, labour and delivery, or during breastfeeding
infant feeding choices, particularly at the time of
(15). Without intervention, an estimated 5% –20%
infant diagnosis and at 6 months.
of infants born to HIV-infected women acquire the
infection through breastfeeding. Transmission can K At 6 months, if adequate feeding from other sourc-
occur at any time while a child is breastfeeding, es cannot be ensured, HIV-infected women should
and continuing to breastfeed until the child is older continue to breastfeed their infants and give com-
increases the overall risk. Exclusive breastfeeding in plementary foods in addition, and return for regu-
the first few months of life carries a lower risk of HIV lar follow-up assessments. All breastfeeding should
transmission than mixed feeding (16). stop once an adequate diet without breast milk can
be provided.
The main factors which increase the risk of HIV
transmission through breastfeeding include (15): K Breastfed infants and young children who are HIV-
infected should continue to breastfeed according
K acquiring HIV infection during breastfeeding,
to recommendations for the general population.
because of high initial viral load;
Women who need anti-retroviral drugs (ARVs) for
K the severity of the disease (as indicated by a low
their own health should receive them, as they are the
CD4+ count or high RNA viral load in the mother’s
women most likely to transmit HIV through breast-
blood, or severe clinical symptoms);
feeding. Comparative studies in women who do not yet
K poor breast health (e.g. mastitis, sub-clinical mas- require treatment on the safety and efficacy of ARVs
titis, fissured nipples); taken during breastfeeding solely to reduce transmis-
K possibly, oral infection in the infant (thrush and sion are ongoing. There is increasing evidence from
herpes); observational studies that women taking ARVs are
likely to have a low risk of transmission (18).
K non-exclusive breastfeeding (mixed feeding);
Five priority areas for national governments in the
K longer duration of breastfeeding; context of the Global Strategy are proposed in HIV
K possibly, nutritional status of the mother. and Infant Feeding: Framework for Priority Action
(19) that has been endorsed by nine United Nations
Current feeding recommendations (17,18) agencies:
The United Nations recommendations for feeding of 1. Develop or revise (as appropriate) a comprehen-
infants by mothers who are HIV- infected include:1 sive national infant and young child feeding policy,
which includes HIV and infant feeding.
K The most appropriate infant feeding option for an
HIV-infected mother depends on her individual 2. Implement and enforce the International Code
circumstances, including her health status and of Marketing of Breast-milk Substitutes and sub-
the local situation, but should take consideration sequent relevant World Health Assembly resolu-
of the health services available and the counselling tions.
and support she is likely to receive.
3. Intensify efforts to protect, promote and support
appropriate infant and young child feeding prac-
1
A full listing can be found in Annex 1 of the HIV and Infant tices in general, while recognising HIV as one of a
Feeding Update (18). number of exceptionally difficult circumstances.
Faculty Guide to integration Breastfeeding in University Curricula
66
60 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
micronutrient mix originally recommended to be 6.6 Feeding non-breastfed children 6–23 months
added to it is not available (25). For women who of age
choose replacement feeding, home-modified animal
Guiding principles
milk should only be used for short times when com-
mercial infant formula is not available. For infants 6 Sometimes young children between the ages of 6
months of age and older, undiluted animal milks can months and 2 years are not breastfed. Reasons include
be added to the diet, and serve as a suitable substi- when their mother is unavailable, or has died, or is
tute for breast milk. The recommended volumes are HIV-positive. These children need extra food to com-
200–400 ml per day if adequate amounts of other ani- pensate for not receiving breast milk, which can pro-
mal source foods are consumed regularly, otherwise vide one half of their energy and nutrient needs from
300–500 ml per day (26). 6 to 12 months, and one third of their needs from
12–23 months (26).
Baby-friendly hospitals and HIV To feed children aged 6–23 months satisfactorily, all
Baby-friendly hospitals have a responsibility to care the principles of safe, adequate complementary feed-
for and support both HIV-positive and HIV-negative ing apply, as described in Session 3. However, to cover
women. the requirements that would otherwise be covered by
breast milk, a child needs to be fed a larger quantity of
K If a mother is HIV-positive, and after counselling
the foods containing high-quality nutrients.
has chosen replacement feeding, this is an accepta-
ble medical reason for giving artificial feeds, and is This can be achieved by giving the child:
thus compatible with a hospital being baby-friend- K extra meals, to help ensure that sufficient amounts
ly. The staff should support her in her choice, and of energy and nutrients are eaten;
teach her how to prepare feeds safely. However, they
K meals of greater energy density, to help ensure that
should give this help privately, and not in front of
sufficient energy is consumed;
other women who may not be HIV-positive. This
is necessary both to comply with the Code, and K larger quantities of foods of animal origin to help
also to prevent the spillover of artificial feeding to ensure that enough nutrients are eaten;
women who do not need it. These women may lose K nutrient supplements, if foods of animal origin are
confidence and interest in their own milk if they not available.
see replacement feeds being prepared.
K If an HIV-positive mother chooses breastfeeding, extra meals
the staff have an equal responsibility to support Non-breastfed children need to eat meals 4–5 times
her to breastfeed exclusively, and to ensure that she per day with additional nutritional snacks 1–2 times
learns a good technique. per day as desired.
K For women who are HIV-negative or of unknown
status, staff should make sure that they are fully energy density of meals
informed and supported to breastfeed optimally. Foods of thick consistency, or with some added fat,
help to ensure an adequate intake of energy for a
Although baby-friendly hospitals should not accept
child.
free or low-cost supplies of breast-milk substitutes
from manufacturers or distributors, the government
may supply them or the hospital or mothers may pur-
Foods of animal origin
chase them for use during the hospital stay. Only the Some meat, poultry, fish, or offal should be eaten eve-
quantity that is actually needed should be available ry day to ensure that the child gets enough iron and
in the hospital, and distribution should be carefully other nutrients (see Table 3 in Session 3.3).
controlled. Dairy products are important to provide calcium. A
A course for hospital administrators provides guid- child needs 200–400 ml of milk or yoghurt every day
ance for how to implement the baby-friendly Ten if other animal source foods are eaten, or 300–500 ml
Steps in settings with high HIV prevalence (27). per day if no other animal source foods are eaten.
References: (refer to more references from the original document of WHO IYCF model chapter) 69
Take Home Messages of session 6: Appropriate feeding in exceptionally difficult
circumstances
Mother’s own milk is best for her preterm circumference (MUAC) of less than 115
of LBW baby and is adapted to its needs. mm.
Most preterms are unable to feed directly Breastfeeding and breastmilk is best for
from the breast so are given expressed malnourished who are at risk of life-
breastmilk (EBM) or donor milk by cup, threatening complications such as
spoon or direct expression in the mouth. hypoglycaemia, hypothermia, serious
Babies less than 32 weeks gestational age infections, dehydration, and severe
usually need to be fed by gastric tube the electrolyte disturbances as it is minimize
amounts differ by age and weight starting such complications.
at 60 ml/kg on day 1, increasing by 10 or The severely malnourished child can be
20 ml per day given 8 times per day (Table treated at home with provision of a ready-
8). to-use therapeutic food (RUTF as F100 or
Preterm babies gain weight at 10–16 F75 if very sick), in addition to
g/kg/day, with smaller babies gaining breastfeeding those 6 months need more
weight more rapidly, infection, frequent breastfeeds and therapeutic feeds.
hypothermia, thrush, anaemia, or Relactation is possible and should be
infrequent feeds interfere with weight gain. started for those not breastfeeding.
Babies are discharged from neonatal care In emergencies, breastfeeding should be
units if gaining weight well >15g/kg/day, encouraged as artificial feeding is more
established on breastfeeding and dangerous because of poor hygiene, lack of
maintaining body temperature. clean water and fuel, and unreliability of
The baby should have follow-up visits at supplies.
least once 2–5 days after discharge, and at In emergencies it is important to identify
least weekly until fully breastfeeding and vulnerable groups, provide adequate food, water
weighing more than 2.5 kg. and nutrients shelter and privacy and
Kangaroo mother care (KMC) is defined as encourage mothers to breastfeed, or to relactate
extended skin-to-skin contact, which helps if they have stopped breastfeeding.
both breastfeeding and bonding, warmth, Excessive supplies may encourage mothers to
stabilized heart rate and respiration and stop breastfeeding and thereby expose their
promoted weight gain, it is continued up to babies to the consequences of the prevailing
2500 gm weight or for as long as the poor hygienic conditions.
mother and baby feel necessary. Babies of HIV mothers should be encouraged
Severe malnutrition in children 6–59 to exclusively breastfeed in the first 2-3
months of age is defined as weight-for- months and thereafter provided a safe
substitute according to the AFFAS criteria.
height less than -3 z-scores, or the presence
of oedema of both feet, or a mid-upper arm
Faculty Guide to integration Breastfeeding in University Curricula
70 Test your Knowledge: Multiple Choice Questions
1) Hypoglycemia, both symptomatic and
asymptomatic, is a common concern in 4) Breastfeeding is contraindicated in which of
healthy term breastfed neonates. While the following conditions:
glucose monitoring should be performed a) Infants with galactosemia
only in high-risk infants and those who are b) Maternal Hepatitis B
symptomatic, the management strategies c) Maternal Hepatitis C
employed to prevent and treat d) Maternal mastitis
hypoglycemia should support breastfeeding.
e) Infants with Cystic Fibrosis
Which one of the following strategies is the
BEST method to prevent symptomatic 5) A mother with a 3-day-old baby
hypoglycemia: presents with sore nipples. The problem
a) Glucose monitoring every thirty minutes began with the first feeding and has
following delivery persisted with every feeding. The most
b) Oral glucose solution by mouth likely source of the problem is:
immediately following birth, followed by
breastfeeding on demand a) Baby’s suck is too strong
c) Early initiation of breastfeeding on b) Feeding time is too long
demand, within 30 – 60 minutes after c) Lack of nipple preparation during
delivery pregnancy
d) Define hypoglycemia < 45 mg/dL (< 2.5 d) Inverted nipples
mmol/L) within the first 3 hours after
delivery e) Poor attachment to the breast
e) All of the above
6) Hospital policies that interfere with
2) The most common cause of poor weight gain
breastfeeding include all of the following
among breastfed infants during the first 4
EXCEPT:
weeks after birth is:
a) Moving the infant to the nursery for the
a) Infant metabolic disorders
night to allow mother to rest and build up
b) Infrequent or ineffective feedings her milk supply
c) Low fat content of breast milk b) Feedings scheduled every 4 hours to allow
d) Maternal endocrine problems mother’s breasts to make more milk
SeSSIon 7
other breastfeeding difficulties
7.4 Mastitis (2) Cause: Usually secondary to mastitis that has not been
Symptoms: There is a hard swelling in the breast, with effectively managed.
redness of the overlying skin and severe pain. Usually Management: An abscess needs to be drained and treat-
only a part of one breast is affected, which is different ed with penicillinase-resistant antibiotics. When pos-
from engorgement, when the whole of both breasts sible drainage should be either by catheter through
are affected. The woman has fever and feels ill. Masti- a small incision, or by needle aspiration (which may
tis is commonest in the first 2–3 weeks after delivery need to be repeated). Placement of a catheter or nee-
but can occur at any time. dle should be guided by ultrasound. A large surgical
Causes: An important cause is long gaps between feeds, incision may damage the areola and milk ducts and
for example when the mother is busy or resumes interfere with subsequent breastfeeding, and should
employment outside the home, or when the baby starts be avoided. The mother may continue to feed from
sleeping through the night. Other causes include poor the affected breast. However, if suckling is too painful
attachment, with incomplete removal of milk; unre- or if the mother is unwilling, she can be shown how to
lieved engorgement; frequent pressure on one part of express her milk, and advised to let her baby start to
the breast from fingers or tight clothing; and trauma. feed from the breast again as soon as the pain is less,
Mastitis is usually caused in the first place by milk usually in 2–3 days. She can continue to feed from the
staying in the breast, or milk stasis, which results in other breast. Feeding from an infected breast does not
non-infective inflammation. Infection may supervene affect the infant (unless the mother is HIV-positive,
if the stasis persists, or if the woman also has a nip- see Session 7.7).
ple fissure that becomes infected. The condition may Sometimes milk drains from the incision if lactation
then become infective mastitis. continues. This dries up after a time and is not a rea-
Management: Improve the removal of milk and try to son to stop breastfeeding.
correct any specific cause that is identified.
7.6 Sore or fissured nipple
K Advise the mother to rest, to breastfeed the baby
Symptoms: The mother has severe nipple pain when the
frequently and to avoid leaving long gaps between
baby is suckling. There may be a visible fissure across
feeds. If she is employed, she should take sick leave
the tip of the nipple or around the base. The nipple
to rest in bed and feed the baby. She should not
may look squashed from side-to-side at the end of a
stop breastfeeding.
feed, with a white pressure line across the tip.
K She may find it helpful to apply warm compresses,
Cause: The main cause of sore and fissured nipples is
to start breastfeeding the baby with the unaffected
poor attachment. This may be due to the baby pulling
breast, to stimulate the oxytocin reflex and milk
the nipple in and out as he or she suckles, and rubbing
flow, and to vary the position of the baby.
the skin against his or her mouth; or it may be due
K She may take analgesics (if available, ibuprofen, to the strong pressure on the nipple resulting from
which also reduces the inflammation of the breast; incorrect suckling.
or paracetamol).
Management: The mother should be helped to improve
K If symptoms are severe, if there is an infected nip- her baby’s position and attachment. Often, as soon as
ple fissure or if no improvement is seen after 24 the baby is well attached, the pain is less. The baby can
hours of improved milk removal, the treatment continue breastfeeding normally. There is no need to
should then include penicillinase-resistant anti- rest the breast – the nipple will heal quickly when it is
biotics (e.g., flucloxacillin). However antibiotics no longer being damaged.
will not be effective without improved removal of
milk. 7.7 Mastitis, abscess and nipple fissure in an HIv-
infected woman (2)
7.5 Breast abscess (2) If a woman is HIV-infected, mastitis, breast abscess
Symptoms: A painful swelling in the breast, which feels and nipple fissure (especially if the nipple is bleeding
full of fluid. There may be discoloration of the skin at or oozing pus) may increase the risk of HIV transmis-
the point of the swelling. sion to the infant. The recommendation to increase
the frequency and duration of feeds is not appropriate
for a mother who is HIV-positive.
7. MAnAGeMenT oF BReAsT CondITIons And oTHeR BReAsTFeedInG dIFFICulTIes 73
67
Management for a woman who is HIv-positive: K There may be a red rash over the nappy area (“dia-
per dermatitis”).
K She should avoid breastfeeding on the affected side
while the condition persists. Cause: This is an infection with the fungus Candida
albicans, which often follows the use of antibiotics in
K She should remove the milk from the affected
the baby or in the mother to treat mastitis or other
breast by expression, to help the breast to recover
infections.
and to maintain the flow of milk. She should be
helped to make sure that she can express her milk Management: Treatment is with gentian violet or nys-
effectively. tatin. If the mother has symptoms, both mother and
baby should be treated. If only the baby has symp-
K If only one breast is affected, the baby can continue
toms, it is not necessary to treat the mother.
to feed on the unaffected breast, and can feed more
often from that side to increase production and Gentian Violet paint:
ensure an adequate intake. Apply 0.25% solution to baby’s mouth daily for 5
days, or until 3 days after lesions heal.
K Give antibiotics for 10–14 days, rest and analgesics
as required, and incision if there is an abscess, as Apply 0.5% solution to mother’s nipples daily for 5
for an HIV-negative woman. days.
K She can resume breastfeeding from the affected Nystatin:
breast when the condition subsides. Nystatin suspension 100,000 IU/ml; apply 1 ml by
dropper to child’s mouth 4 times daily after breast-
K Some mothers decide to stop breastfeeding at this
feeds for 7 days, or as long as the mother is being
time if they are able to give replacement feeds safe-
treated.
ly. They should continue to express enough milk to
allow the breasts to recover, until milk production Nystatin cream 100,000 IU/ml; apply to nipples 4
ceases. times daily after breastfeeds. Continue to apply for 7
days after lesions have healed.
K If both breasts are affected, she will not be able
to feed the baby from either side, and will need
to consider other feeding options as a permanent 7.9 Inverted, flat, large and long nipples (3)
solution. She may decide to heat-treat her own Signs to look for: Nipples naturally occur in a wide vari-
milk and give that, or to give formula. She should ety of shapes that usually do not affect a mother’s
feed the baby by cup. ability to breastfeed successfully. However, some nip-
ples look flat, large or long, and the baby has difficulty
7.8 Candida infection (thrush) in mother and baby attaching to them. Most flat nipples are protractile –
(3) if the mother pulls them out with her fingers, they
stretch, in the same way that they have to stretch in
Symptoms:
the baby’s mouth. A baby should have no difficulty
In the mother: suckling from a protractile nipple. Sometimes an
K Sore nipples with pain continuing between feeds, inverted nipple is non-protractile and does not stretch
pain like sharp needles going deep into the breast, out when pulled; instead, the tip goes in. This makes
which is not relieved by improved attachment. it more difficult for the baby to attach. Protractil-
ity often improves during pregnancy and in the first
K There may be a red or flaky rash on the areola, with week or so after a baby is born. A large or long nipple
itching and depigmentation. may make it difficult for a baby to take enough breast
In the baby: tissue into his or her mouth. Sometimes the base of
the nipple is visible even though the baby has a widely-
K White spots inside the cheeks or over the tongue,
open mouth.
which look like milk curds, but they cannot be
removed easily. Cause: Different nipple shapes are a natural physical
feature of the breast. An inverted nipple is held by
K Some babies feed normally, some feed for a short
tight connective tissue that may slacken after a baby
time and then pull away, some refuse to feed alto-
suckles from it for a time.
gether, and some are distressed when they try to
attach and feed, suggesting that their mouth is sore.
Faculty Guide to integration Breastfeeding in University Curricula
74
68 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
In some cases, a baby does have a low intake of breast If the baby has a low milk intake, then it is necessary
milk, insufficient for his or her needs. Occasional- to find out if it is due to breastfeeding technique, or
ly, this is because the mother has a physiological or low breast-milk production.
pathological low breast-milk production (4). Usually,
7. MAnAGeMenT oF BReAsT CondITIons And oTHeR BReAsTFeedInG dIFFICulTIes 75
69
If the baby’s intake is adequate, then it is necessary to physical condition; and baby’s condition (illness or
decide the reasons for the signs that are worrying the abnormality).
mother.
Breastfeeding factors
Low Breast-miLk intake A low breast-milk intake may be due to:
Signs: There are two reliable signs that a baby is not
K delayed initiation of breastfeeding, so that milk
getting enough milk:
production does not adjust in the early days to
K poor weight gain. match the infant’s needs;
K low urine output. K poor attachment, so that the baby does not take the
milk from the breast efficiently;
Passing meconium (sticky black stools) 4 days after
delivery is also a sign of the baby not getting enough K infrequent feeds, feeds at fixed times or no night
milk. feeds, so that the baby simply does not suckle
enough; breastfeeding less than 8 times in 24 hours
Poor weight gain in the first 8 weeks, or less than 5–6 times in 24
Babies’ weight gain is variable, and each child follows hours after 8 weeks;
his or her own pattern. You cannot tell from a single K short feeds, if a mother is very hurried, or if she
weighing if a baby is growing satisfactorily – it is nec- takes the baby off the breast during a pause before
essary to weigh several times over a few days at least he or she has finished, or if the baby stops quickly
(see Annex 3 for tables showing the range of weights for because he is wrapped up and too hot, then he or
babies of different birth weights). she may not take as much milk as needed, espe-
Soon after birth a baby may lose weight for a few days. cially the fat-rich hind milk;
Most recover their birth weight by the end of the first K using bottles or pacifiers which replace suckling at
week, if they are healthy and feeding well. All babies the breast, so the baby suckles less. Babies who use
should recover their birth weight by 2 weeks of age. A pacifiers tend to breastfeed for a shorter period.
baby who is below his or her birth weight at the end of Pacifiers may be a marker or a cause of breastfeed-
the second week needs to be assessed. ing failure (5). They may interfere with attach-
From 2 weeks, babies who are breastfed may gain from ment, so the baby suckles less effectively;
about 500 g to 1 kg or more each month. All these K giving other foods or drinks causes the baby to
weight gains are normal. The baby should be checked suckle less at the breast and take less milk, and also
for illness or congenital abnormality and urine out- stimulates the breast less, so less milk is produced.
put. The technique and pattern of breastfeeding, and
the mother-baby interaction should also be assessed, Psychological factors of the mother
to decide the cause of poor weight gain, as explained
A mother may be depressed, lacking in confidence,
below.
worried, or stressed; or she may reject the baby or
dislike the idea of breastfeeding. These factors do
low urine output not directly affect her milk production, but can
An exclusively breastfed baby who is taking enough interfere with the way in which she responds to her
milk usually passes dilute urine 6-8 times or more in baby, so that she breastfeeds less. This can result in
24 hours. If a baby is passing urine less than 6 times the baby taking less milk, and failing to stimulate
a day, especially if the urine is dark yellow and strong milk production.
smelling, then he or she is not getting enough fluid.
This is a useful way to find out quickly if a baby is Mother’s physical condition
probably taking enough milk or not. However, it is
A few mothers have low milk production for a patho-
not useful if the baby is having other drinks in addi-
logical reason including endocrine problems (pitui-
tion to breast milk.
tary failure after severe haemorrhage, retained piece
Causes: The reasons for a low breast-milk intake are of placenta) or poor breast development. A few moth-
summarised in Table 9, and classified as breastfeeding ers have a physiological low breast-milk production,
factors; psychological factors with mother; mother’s for no apparent reason, and production does not
Faculty Guide to integration Breastfeeding in University Curricula
76
70 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
TABle 9
Reasons why a baby may not get enough breast milk
BReASTFeedInG FACToRS MoTHeR: PSyCHoLoGICAL FACToRS MoTHeR: PHySICAL CondITIon BABy’S CondITIon
increase when the breastfeeding technique and pat- K suckles for a long time at each feed (more than one
tern improve. half hour, unless newborn or low birth weight);
Other factors that can reduce milk production tem- K is generally unsettled.
porarily include hormone-containing contraceptive
Management of perceived insufficiency and low breast milk
pills, pregnancy, severe malnutrition, smoking and
production: A health worker may use counselling skills
alcohol consumption.
to listen and learn, to take a feeding history and to
understand the difficulty, particularly if there may
Baby’s condition
be psychological factors affecting breastfeeding. A
A baby may fail to gain weight, or may fail to breast- breastfeed should be observed, checking the baby’s
feed well and stimulate milk production because of attachment. The mother’s physical condition and the
illness, prematurity or congenital abnormality, such baby’s condition and weight should also be noted. A
as a palate defect, heart condition or kidney abnor- health worker should decide if the difficulty is due to
mality. It is always important to consider these factors low milk intake, or perceived insufficiency.
and to examine a baby carefully before concluding
that a mother has low breast-milk production. If the difficulty is low milk intake, a health worker
should:
Conclusion K decide the reason for the low milk intake;
The common reasons for a baby not getting enough K treat or refer the baby, if there is any illness or
breast milk are due to poor technique or mismanage- abnormality;
ment of breastfeeding, which can be overcome. Only
a few mothers have long-term difficulty with milk K help the mother with any of the less common caus-
production. es, for example if she is using oestrogen-containing
contraceptive pills. Referral may be necessary;
Perceived insufficiency K discuss how the mother can improve her breast-
Signs: If a baby is gaining weight according to the feeding technique and pattern and improve the
expected growth velocity, and is passing dilute urine 6 baby’s attachment;
or more times in 24 hours, then his or her milk intake K use counselling skills to help her with any psycho-
is adequate. If the mother thinks that she does not logical factors, and to build her confidence in her
have enough milk, then it is perceived insufficiency. milk supply.
Causes: Poor attachment is likely to be the cause if a If the difficulty is perceived insufficiency, the health
baby: worker should:
K wants to feed very often (more often than 2 hour-
K decide the reason;
ly all the time, with no long intervals between
feeds); K explain the difficulty, and what might help;
7. MAnAGeMenT oF BReAsT CondITIons And oTHeR BReAsTFeedInG dIFFICulTIes 77
71
7.11 Crying baby K For colic or a high-needs baby, the mother can
carry and rock the baby with gentle pressure on the
Signs or symptoms: The baby cries excessively, and is
abdomen. She may need reassurance that the cry-
difficult to comfort. The pattern of crying may sug-
ing will lessen as the baby grows.
gest the cause.
Cause: 7.12 oversupply of breast milk
K Pain or illness. This may be the case when a baby Symptoms:
suddenly cries more than before.
K The baby cries as if he or she has colic and wants to
K Hunger due to sudden faster growth, common at ages feed often.
2 weeks, 6 weeks and 3 months (sometimes called a
K The baby may have frequent loose stools, which
“growth spurt”). If the baby feeds more often for a
may be green.
few days, the breast milk supply increases and the
problem resolves. K He or she may grow well, or may have poor weight
gain, suggesting low milk production.
K Sensitivity to substances from the mother’s food. This
may be any food, but is commonly milk, soy, egg K The mother may have a forceful oxytocin reflex, so
or peanuts. Caffeine in coffee, tea and colas, and that her milk flows fast. This can make the baby
substances from cigarette smoke can also upset a choke and pull away from the breast during feeds.
baby. If the mother avoids the food or drink that Cause:
may be causing the problem, the baby cries less.
K The baby may be poorly attached, and suckling a
K Gastro-oesophageal reflux. The baby cries after lot but not removing the milk efficiently. Constant
feeds, often on lying down, and may vomit a large suckling may stimulate the breast to produce a lot
amount of the feed, more than the slight regurgi- of milk.
tation that is very common. The opening between
the oesophagus and the stomach (cardiac orifice) is K The mother may take her baby off the first breast
weak, allowing milk to flow back into the oesopha- before he or she has finished to put him on the sec-
gus, which can cause pain. ond breast. The baby may get mostly low-fat fore
milk, and suckle more to get more energy, and so
K Colic. Often crying occurs at certain times of day, stimulate the breasts to make more milk.
typically the evening. The baby may pull up his legs
as if in pain. He or she wants to feed but is difficult K Large amounts of foremilk overload the baby
to comfort. The cause is not clear. Babies with colic with lactose, causing loose stools and colicky
usually grow well, and the crying decreases after behaviour.
3–4 months. Carrying the baby more, using a gen- Management:
tle rocking movement, and pressure on the abdo-
men with the hands, or against the shoulder, may K The mother should be helped to improve her baby’s
help. attachment.
K High-needs babies. Some babies cry more than oth- K The mother should offer only one breast at each
ers, and they need to be carried and held more. feed, until the baby finishes by him- or herself. The
This problem is less common in communities baby will get more fat-rich hindmilk. She should
where mothers carry their babies with them, and offer the other breast at the next feed.
keep them in the same bed.
Faculty Guide to integration Breastfeeding in University Curricula
78
72 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
K If a forceful oxytocin reflex continues, she can lie K avoid shaking her breast or pressing the baby’s
on her back to breastfeed, or hold the breast with head to force him or her to the breast;
her fingers closer to the areola during feeds.
K feed the baby by cup, if possible with her own
breast milk, until he or she is willing to take the
7.13 Refusal to breastfeed breast again.
Symptoms: The baby refuses to breastfeed, and may cry,
arch his or her back, and turn away when put to the 7.14 Twins
breast. The mother may feel rejected and frustrated,
Management
and be in great distress.
Twins who are low birth weight need to be managed
Causes: There may be a physical problem such as:
accordingly (see Session 6.1).
K illness, an infection, or a sore mouth, for example
For larger twins, management should be as for single-
thrush (see Session 7.8);
tons, with early contact, help to achieve good attach-
K pain, for example bruising after a traumatic deliv- ment at the breast, and exclusive on-demand feeding
ery or gastro-oesophageal reflux; from birth, or from as soon as the mother is able to
respond. Early effective suckling can ensure an ade-
K sedation, if the mother received analgesics during
quate milk supply for both infants.
labour.
Mothers may need help to find the best way to hold
The baby may have difficulty or frustration with
two babies to suckle, either at the same time, or one at
breastfeeding because of:
a time. They may like to give each baby its own breast,
K sucking on a bottle or pacifier; or to vary the side. Holding one or both babies in the
K difficulty attaching to the breast; underarm position for feeding, and support for the
babies with pillows or folded clothes is often helpful.
K pressure applied to his or her head by someone Building the mother’s confidence that she can make
helping with positioning; enough milk for two, and encouraging relatives to
K the mother shaking her breast when trying to help with other household duties, may help her to
attach him or her. avoid trying to feed the babies artificially.
Most mothers can breastfeed normally after a caesar- K express milk in the morning before she leaves for
ean delivery if they are given appropriate help. Dif- work;
ficulties in the past have often been because mothers K express her milk while she is at work to keep up
did not receive enough help to establish breastfeeding the supply. She can refrigerate the milk if this is
in the post-operative period, and because babies were possible, or keep it for up to 8 hours at room tem-
given other feeds meanwhile. perature and bring it home. If this is not possible,
If a baby is too ill or too small to fed from the breast she may have to discard it. She needs to understand
soon after delivery, the mother should be helped that the milk is not lost – her breasts will make
to express her milk to establish the supply, starting more. If a mother does not express when at work,
within 6 hours of delivery or as soon as possible, in her milk production will decrease.
the same way as after a vaginal delivery (see Session
4.5). The EBM can be frozen for use when the baby is temPorary seParation for otHer reasons
able to take oral feeds. A mother and her baby may be separated and unable
If the mother is too ill to breastfeed, the baby should to breastfeed if either of them is ill and admitted to
be given artificial milk or banked breast milk by cup hospital, or if the baby is LBW or has problems at birth
until the mother is able to start breastfeeding. and is in the Special Care Baby Unit (see Session 6.1).
Management
7.16 Mother separated from her baby
While separated, encourage the mother to express
sHort-term seParation sucH as emPLoyment outside her milk as often as the baby would feed, in order to
tHe Home establish or keep up the supply. If facilities are avail-
The commonest reason for a mother being separated able, she can store her milk by freezing it (see Session
from her baby for part of the day is because she is 4.5). Help the baby to start breastfeeding as soon as he
employed outside the home, for example when mater- or she is able and can be with the mother again.
nity leave is not adequate to enable her to continue
breastfeeding exclusively for 6 months. 7.17 Illness, jaundice and abnormality of the child
Management iLLness
Options should be discussed with the mother. She Symptoms related to feeding
should be encouraged to breastfeed the baby as much K The infant may want to breastfeed more often than
as possible when she is at home, and to consider before.
expressing her milk to leave for someone else to give
to her baby. K Local symptoms such as a blocked nose, or oral
thrush can interfere with suckling. The infant may
suckle for only a short time and not take enough
expressing her milk for the baby
milk.
A trained health worker should teach her how to
express and store her breast milk (see Session 4.5), how K The infant may be too weak to suckle adequately,
to feed her baby by cup (Session 4.6), and why it is best or may be unable to suckle at all.
to avoid using a feeding bottle. K During surgery an infant may not be able to receive
any oral or enteral feeds.
Management: Infants and young children who are ill
should continue to breastfeed as much as possible,
Faculty Guide to integration Breastfeeding in University Curricula
80
74 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
while they receive other treatment. Breast milk is the and to feed her infant using supplementary suckling
ideal food during illness, especially for infants less to stimulate breast-milk production (see Session 6.4).
than 6 months old, and helps them to recover. With appropriate skilled support, many mothers can
resume exclusive breastfeeding within 1–2 weeks.
Babies under 6 months of age
If a baby is in hospital, the mother should be allowed Infants and young children over 6 months of age
to stay with him or her, and to have unrestricted A young child may prefer breastfeeding to comple-
access so that she can respond to and feed the baby mentary foods while he or she is ill, and breastfeed
as needed. more than before. Milk production may increase,
so that the mother notices increased fullness of her
If a baby has a blocked nose breasts. She should be encouraged to stay with her
The mother can be taught how to use drops of salt- child in hospital and to breastfeed on demand.
ed water or breast milk, and clear the baby’s nose by The mother or caregiver should continue to offer
making a wick with a twist of tissue. She can give complementary foods, which may need to be given
shorter more frequent breastfeeds, allowing the baby more often, in smaller quantities and of a softer con-
time to pause and breathe through the mouth until sistency than when the child is well. Offer extra food
the nose clears. during recovery as the child’s appetite increases.
continue breastfeeding until the infant has been fully This is effective and can now be done simply and
assessed. safely (6).
1
Refusal to feed is commonly attributed to these organs and easy to digest so 83
oral pain, sick baby, use of artificial preserves energy stores in face of higher
nipples (bottles or pacifiers), or poor metabolic requirements of these
attachment. conditions, assisting response to treatment.
Mothers can produce enough milk for Sick and small babies take a longer time
multiple births (twins or more), but needs to breastfeed and may not be able to finish
social support and guidance in positioning the feed so should be fed expressed
both babies at the breasts, building her breastmilk by cup or dropper.
confidence and close follow-up. After recovery breastfeeding and skin to
Exaggerated physiological jaundice can skin care is encouraged to help open the
be prevented or reduced by frequent early lungs to improve oxygenation and growth.
correct breastfeeding not by giving Babies with cleft lip or palate or other
supplements or bottle feeds to the baby. oro-facial abnormality can be assisted to
Babies with heart failure or renal failure continue breastfeeding by different
benefit from breastfeeding as breastmilk is techniques or feeding expressed
low in salt placing low solute load on breastmilk.
Test your knowledge : Multiple choice questions
1) Mastitis is most often due to: a) Infants with phenylketonuria
a) High prolactin levels b) Infant with heart failure
b) Unrelieved engorgement c) Infant with renal failure
c) Postpartum depression d) Premature baby
d) Epidural anesthesia e) Infants with Cystic Fibrosis
e) None of the above 5) A 3-day-old baby presents with
2) The most common cause of poor weight dehydration. The problem began when
gain among breastfed infants during the mother developed postpartum depression.
first 4 weeks after birth is: The most likely source of the problem is:
a) Infant metabolic disorders a) Baby’s suck is too strong
2
Faculty Guide to integration Breastfeeding in University Curricula
84 that a woman with inverted nipples do c) moist heat to the involved region
during the third trimester? d) antibiotics for 10 to 14 days
a) Use breast shells with guidance from 9) Nipple candidiasis can be associated with all of the
her health care provider following EXCEPT:
b) Cut holes in the bra to allow the
a) oral thrush in the infant
nipples to protrude; wear it day and
night b) burning pain in the breast
c) Encourage everting the nipples four c) fever and malaise
times a day to permanently evert her
nipples d) pink and shiny appearance of the nipples and
areola
d) Do nothing because the natural
changes in the breast during 10) Jaundice in a normal full term breastfeeding infant
pregnancy and the infant’s suckling is improved by:
postpartum may evert the nipples a) giving glucose water after breastfeeding
8) A breastfeeding mother with a 3-month old infant b) giving water after breastfeeding
has a red tender wedge-shaped area on the outer
quadrant of one breast. She has flu-like symptoms c) breastfeeding frequently (at least 8 or more
and a temperature of 39C. Your management times in 24 hours)
includes all of the following EXCEPT: d) both a and c
a) extra rest
Karim is a 3 day exclusively breastfed full term baby Follow up visit: The dyad have some problems
born after a normal vaginal delivery. The baby nursed feeding but once the baby’s stool output increased
well in the delivery room within an hour after and the bilirubin subsequently decreased without
delivery. She has been feeding every 3 hours since. other intervention. The baby returns to the
The baby’s last stool, about 18 hours ago, was black pediatrician’s office at 14 days of age and has scleral
and tarry. The baby and mother have the same blood icterus, and jaundice visible to the chest. The baby is
type. A bedside transcutaneous bilirubin passing stool 4 times a day, gaining weight and
measurement at 24 hours of age places the baby in mother is not experiencing any further pain. TCBM is
the “high intermediate” range. 14.
3
85
Mother’s health
SeSSIon 8
When counselling a mother on infant and young take enough food to cover any extra needs. However,
child feeding, it is important to remember her own a woman with a poor diet may not have laid down
health, and care for her as well as the baby. Issues to body stores in pregnancy. She needs to eat an extra
address include any illness she may have, her nutri- meal with a variety of foods each day to cover her
tional status and food intake, maternal medication, needs and protect those stores that she has.
and birth spacing and family planning.
It is generally helpful to advise the woman to eat a
greater amount and variety of foods, such as meat,
8.1 Mother’s Illness fish, oils, nuts, seeds, cereals, beans, vegetables, cheese
If a mother has an illness or other condition, it is and milk, to help her feel well and strong. It is impor-
important to consider what effect it might have on tant to determine if there are taboos about foods, and
breastfeeding. She may need extra support to enable to advise against any harmful taboos. Pregnant and
her to breastfeed, for example if she has a disability, lactating women can eat any foods normally included
or is mentally ill. If a mother is very ill and unable in the local diet – these will not harm the breastfeed-
to breastfeed, options for feeding her infant or child ing baby. Very thin women and adolescents require
until she can resume will need to be considered. special attention, and they may need more intensive
nutrition counselling. Family members, such as the
If a mother has tuberculosis, she and her infant should
partner and mother-in-law, also influence a mother’s
be treated together according to national guidelines,
feeding practices. They can help to ensure that the
and breastfeeding should continue (1).
woman eats enough and avoids hard physical work.
If a mother has hepatitis (A, B, or C) breastfeeding
If extra food is not available, this should not prevent
can continue normally as the risk of transmission by
a mother from breastfeeding. Even when a woman
breastfeeding is very low (2).
is moderately malnourished, she continues to pro-
If a mother is HIV-positive, she needs counselling duce good quality breast milk. Only when a woman
about different feeding options and support for her is seriously malnourished does the quantity of breast
choice (see Session 6.5). milk decrease. Where household resources are scarce,
breast milk is likely to be the most complete and safest
8.2 Maternal nutrition (3) food for the baby, and breastfeeding the most efficient
During lactation, a mother’s intake should be way for the mother to use her own and her family’s
increased to cover the energy cost of breastfeeding: resources to feed the child.
by about 10% if the woman is not physically active, Mothers with specific micronutrient deficiencies may
but 20% or more if she is moderately or very active. A need supplements of fortified products both for their
diet that is poor in quantity or quality may affect her own health and that of their breastfeeding infants.
energy and ability to breastfeed or to feed and care
for her infant or child. In practice, a lactating mother 8.3 Medication and drugs (4)
uses about 500 kilocalories (roughly equivalent to one
Some medications taken by a mother may pass into her
extra meal) each day to make 750 ml of breast milk
milk. There are very few medicines for which breast-
for an infant. Some nutrients come from her body
feeding is absolutely contra-indicated. However there
stores, laid down during pregnancy. Others need to
are some medicines that can cause side-effects in the
come from an increased intake.
baby – they may warrant use of a safer alternative or
A woman who is well nourished with a varied diet avoidance of breastfeeding temporarily. Table 10 pro-
and who eats according to her appetite will usually vides a guidance for medicines listed in the Eleventh
Faculty Guide to integration Breastfeeding in University Curricula
86
78 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
TABle 10
Breastfeeding and mother’s medication
WHO Model List of Essential Drugs (4), while Annex 1 ovulation, and so delay the return of menstruation
includes an additional summary of medicines with and fertility after childbirth (see Session 2.5). This is
side-effects. called the Lactation Amenorrhoea Method (LAM),
and all mothers of infants and young children should
8.4 Family planning and breastfeeding know about it. They also need to know the limita-
The harmful effects of pregnancies too close together tions of LAM, including when they are not protected
are well recognized. Birth-to-pregnancy intervals of against pregnancy, even if they are breastfeeding.
6 months or shorter are associated with a higher risk LAM is effective under the following three conditions
of maternal mortality. Birth-to-pregnancy intervals of (see Box 18):
around 18 months or less are associated with a signifi-
The mother must be amenorrhoeic – that is, she must
cantly higher risk of neonatal and infant mortality, low
not be menstruating. If she menstruates, it is a sign
birth weight, small size for gestational age and preterm
that her fertility has returned, and she can become
birth. Couples should be advised to wait at least 24
pregnant again.
months after a live birth and 6 months after a miscar-
riage before attempting the next pregnancy (5). The baby must breastfeed exclusively,1 and feed fre-
quently during both day and night. If the baby has
8.4.1 Lactational Amenorrhoea Method (6,7) any artificial feeds, or complementary food, then he
Breastfeeding is an important method of family
planning, because it is available to women who are 1
Evidence shows that LAM remains effective even if a baby is
unable for social or other reasons to obtain or use fully or nearly fully breastfed (meaning that the child may have
received vitamins, minerals, water, juice or ritualistic feeds
modern contraceptives, and it is under their control. infrequently in addition to breastfeeds), as long as the vast
Hormones produced when a baby suckles prevent majority of feeds are breastfeeds
8. MoTHeR’s HeAlTH 87
79
Drugs transfer into human milk largely as a Advise the mother to feed the infant and then
function of physicochemical characteristics, to take her medication to avoid breastfeeding
which include molecular weight, lipophilicity, when it peaks in the maternal plasma.
protein binding and pKa. Evaluate the age, stability, maturity and
Maternal factors include the plasma level of condition of the infant in order to determine if
the medication, with higher transfer occurring the infant can handle exposure to the
when levels peak in the maternal plasma medication.
compartment (Cmax). Mothers with unstable neonates in special
Avoid using medications when not absolutely care; should avoid taking medication or pump
necessary. This includes most herbal drugs. milk before taking medication.
Choose drugs with shorter half-lives over Choose medications that are commonly used
those with longer half-lives. in pediatric patients and are considered safe.
Choose drugs with less toxicity and those Choose medications such as warfarin with
commonly used in infants. high protein binding or with higher molecular
Choose drugs with poorer bioavailability to weights as heparin because tissue and milk
reduce oral absorption in infants. levels will be lower.
1
Choose medications such as domperidone with Watch for side effects in the baby or monitor 89
poor blood/brain penetration as they usually drug levels in baby.
produce lower milk levels.
Test your knowledge: Choose only one appropriate response
1) All of the following medications given e) “Pins and needles” sensation in the
during a nursing mother’s hospitalization breast
are compatible with uninterrupted 5) All of the following will influence
breastfeeding EXCEPT: maternal milk production EXCEPT:
a) Acetaminophen a) Retained placental fragments
a) Milk leaking from the other breast c) using medications with lower protein-
binding capacity
b) Uterine cramping
d) using higher molecular weight medications
c) Breast erythema
d) Audible swallowing
Answers to MCQs: 1=b, 2=e, 3=e, 4= c, 5= d, 6= b,
7= d, 8=c.
2
Faculty Guide to integration Breastfeeding in University Curricula
90 Objective Structured Clinical Examination Case Study:
SET UP
Yes
Concerns about mother health during Yes
breastfeeding
WHO growth charts for breastfed children*
Breastfeeding Observation Aid (BOA)*
Taking history form: (UNICEF/WHO BFHI
Demonstrate obtaining an appropriate
20 hour course)*
history from a postpartum mother who is Objective Structured Clinical
attempting to breastfeed, medication Examination Case Study: Standardized
history and history of medical condition Patient Description and Script (see AAP
Assess current breastfeeding technique residency curriculum tools)
Instruct mother in proper breastfeeding
Objective Structured Clinical
technique
Examination Case Study:
Educate mother about breastfeeding and
Performance Assessment ((see AAP
anticipate common breastfeeding problems
residency curriculum tools)
and concerns
* See Annex 2 for growth charts, BOA form and infant feeding history form
91
Policy, health system and
SeSSIon 9
community actions
The Global Strategy for Infant and Young Child Feeding K Ensure that the health and other relevant sectors
(1) is the overarching framework for action by gov- protect, promote and support exclusive breastfeed-
ernments and all concerned parties to ensure that the ing for 6 months and continued breastfeeding up
health and other sectors are able to protect, promote to 2 years of age or beyond, while providing women
and support appropriate infant and young child feed- access to the support they require – in the family,
ing practices. The Global Strategy was endorsed unan- community and workplace – to achieve this goal;
imously by WHO Member States in the 55th World
K Promote timely, adequate, safe and appropriate
Health Assembly in 2002 and adopted by UNICEF’s
complementary feeding with continued breast-
Executive Board in the same year.
feeding;
The Global Strategy reaffirms and builds on the Inno-
K Provide guidance on feeding infants and young
centi Declaration on the Protection, Promotion and
children in exceptionally difficult circumstances,
Support of Breastfeeding that was adopted in 1990 and
and on the related support required by mothers,
revitalized in 2005. It identifies four operational tar-
families and other caregivers;
gets (2):
K Consider what new legislation or other suitable
K Appoint a national breastfeeding co-ordinator
measures may be required, as part of a comprehen-
with appropriate authority, and establish a multi-
sive policy on infant and young child feeding, to
sectoral national breastfeeding committee com-
give effect to the principles and aim of the Code.
posed of representatives from relevant government
departments, non-governmental organisations To implement the Global Strategy, actions at interna-
(NGOs) and health professional associations; tional, national and local level are needed to:
K Ensure that every facility providing maternity serv- K Strengthen policies and legislation to protect infant
ices fully practises all of the “Ten steps to success- and young child feeding;
ful breastfeeding” set out in the WHO/UNICEF K Strengthen health system and health services to
statement on breastfeeding and maternity services support optimal infant and young child feeding;
(3);
K Strengthen actions to promote and support optimal
K Give effect to the principles and aim of the Inter- infant and young child feeding practices within
national Code of Marketing of Breast-milk Sub- families and communities.
stitutes and subsequent relevant Health Assembly
resolutions in their entirety (4);
9.1 Strengthening national policies and
K Enact imaginative legislation protecting the breast- legislation
feeding rights of working women and establishing A primary obligation of governments is to formulate,
means for its enforcement (5). implement, monitor and evaluate a comprehensive
The Global Strategy includes five additional targets, national policy on infant and young child feeding
namely: (see Figure 22), to ensure a better use of resources and
coordination of efforts.
K Develop, implement, monitor and evaluate a
comprehensive policy on infant and young child Internationally recognized policy instruments to pro-
feeding, in the context of national policies and mote, protect and support optimal infant and young
programmes for nutrition, child and reproductive child feeding practices include the:
health, and poverty reduction; K United Nations Convention on the Rights of the
Child (CRC)
Faculty Guide to integration Breastfeeding in University Curricula
92
82 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
FIGuRe 22
elements of a comprehensive infant and young feeding programme
PoLICy
K national coordinator and coordinating body
for infant and young child feeding
K Health system norms
K Code of marketing of breast-milk substitutes
K Worksite laws and regulations
K Information, education and communication
K International Code of Marketing of Breast-milk Sub- the advantages of breastfeeding”. The CRC is an
stitutes, and subsequent relevant WHA resolutions important tool to hold governments to account on
progress in the area of infant and young child feeding.
K International Labour Organization (ILO) Maternity
The periodic review and reporting process also pro-
Protection Convention 2000 (183).
vides an entry point for making recommendations to
strengthen national plans and actions in the area of
9.1.1 Convention on the Rights of the Child
infant and young child feeding.
The CRC is an instrument for protecting and ful-
filling the rights of children (6). It was adopted by
United Nations member states almost universally in 9.1.2 International Code of Marketing of Breast-milk
November 1989, and countries which have agreed to Substitutes and subsequent relevant Health Assembly
it (also referred to as States Parties) are required to resolutions – the Code
report regularly to the United Nations about progress The Code was adopted by WHO Member States in
in implementation. 1981 in response to the realization that wide-spread
marketing of breast-milk substitutes was leading to
Article 24 of the CRC addresses child health and
adverse health outcomes in infant and young children
nutrition, and some quotations are particularly rel-
all over the world (4). Progress in the implementa-
evant. States Parties agree to “take appropriate meas-
tion of the Code is reported every alternate year in the
ures to diminish infant and child mortality”, and “to
World Health Assembly (WHA), and through this
combat disease and malnutrition … through the pro-
process, a series of resolutions to further clarify the
vision of adequate nutritious foods and clean drink-
Code have been adopted by WHO Member States.
ing water”; and to “ensure that all segments of society,
particularly parents and children, are informed, have Manufacturers of infant formula often promote and
access to education and are supported in the use of market their products in ways which encourage moth-
basic knowledge of child health and nutrition, and ers and health workers to believe that breastfeeding
9. PolICY, HeAlTH sYsTeM And CoMMunITY ACTIons 93
83
and artificial feeding are equivalent. This under- and their children. This consensus is reflected in the
mines mothers’ confidence in breast milk and in their international labour standards of the ILO, which set
ability to breastfeed according to global recommen- out basic requirements of maternity protection at
dations. The Code seeks to regulate the marketing of work. ILO Maternity Protection Convention No. 183,
breast-milk substitutes, including infant formula and adopted by ILO Member States in 2000 (5), covers:
other milk products, foods and drinks, and bottle-
K 14 weeks of maternity leave, including 6 weeks of
fed complementary foods, when they are presented as
compulsory postnatal leave;
replacements for breast milk. The Code also seeks to
regulate the marketing of feeding bottles and teats. K cash benefits during leave of at least two thirds of
previous or insured earnings;
The Code addresses the quality and availability of the
products, and information concerning their use. It K access to medical care, including prenatal, child-
provides recommendations concerning the market- birth and postnatal care, as well as hospitalization
ing of industrially-prepared complementary foods, when necessary;
encouraging the use of locally-available foods. Thus K health protection: the right of pregnant and nurs-
the Code does not seek to ban products, but to control ing women not to perform work prejudicial to their
promotion that may influence families to use them health or that of their child;
when they are not needed.
K breastfeeding: minimum one daily break, with pay;
Health workers have important responsibilities to
K employment protection and non-discrimination.
comply with the provisions of the Code (7). For exam-
ple, health care facilities should not be used for the Few countries have ratified this Convention, although
purpose of promoting or displaying infant formula or many countries have adopted some provisions
other products within the scope of the Code. If prepa- through ratification of previous ILO maternity pro-
ration of formula feeds has to be demonstrated, this tection conventions. Health professionals have an
should be done only by trained health workers and important role to advocate for good legislation on
only to mothers or family members who need to use maternity protection, and hospitals and other health
formula, or who have made an informed decision to facilities should offer maternity leave and breastfeed-
do so. Health workers should explain clearly the dan- ing support for their own personnel.
gers of using the products.
9.2 Strengthening the health system and
Health facility administrators and staff need to
health services
understand and fulfil their responsibilities under the
Code. These include: Health workers have a critical role in protecting,
promoting and supporting infant and young child
K to encourage and protect breastfeeding; feeding. The advice given by health workers has been
K not to accept financial or material inducements to identified as one of the key determinants influencing
promote these products; mothers’ feeding practices. Health workers therefore
should have the necessary knowledge and skills to
K not to give samples of infant formula to pregnant
counsel caregivers and help them overcome feeding
women, mothers of infants and young children, or
difficulties when they occur. They should comply
members of their families.
with the Code and ensure that breast-milk substitutes
The fact that HIV can be transmitted through breast are not displayed in the health facility but only intro-
milk should not undermine efforts to implement the duced to those mothers and babies who need them.
Code. HIV-positive mothers, as all women, need to be To protect, promote and support optimal infant and
protected from commercial promotion of infant for- young child feeding, health services should:
mula and other products, and to remain free to make
an informed decision regarding infant feeding. The K Adhere to the Code and maternity protection legis-
Code fully covers their needs. lation for their own workers;
K Implement and maintain the BFHI (see Session 4);
9.1.3 ILO Maternity Protection Convention, 2000 (No. 183) K Ensure that health workers are trained and sup-
Maternity protection at work is essential for safe- ported to provide breastfeeding counselling and
guarding the health and economic security of women complementary feeding counselling (see Session 5);
Faculty Guide to integration Breastfeeding in University Curricula
94
84 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
The ENA approach promotes seven essential nutri- K training and support of community health workers;
tion actions: K training and support of lay or peer counsellors;
K exclusive breastfeeding from birth to 6 months; K fostering breastfeeding support groups.
K appropriate complementary feeding from 6 months
with continued breastfeeding up to 24 months or 9.3.1 Behaviour change communication
beyond; Mothers do not make infant or young child feeding
K appropriate feeding of infants and young children decisions alone. Other people in the family and com-
during and after illness; munity influence them. To improve practices, a com-
munication strategy must address the beliefs of these
K adequate nutrition of women; other people, so that there is a change in family and
K control of vitamin A deficiency; community norms.
K control of anaemia through iron supplementation When developing a communication strategy, it is use-
and de-worming of women and children; ful to understand the stages of an individual person’s
9. PolICY, HeAlTH sYsTeM And CoMMunITY ACTIons 95
85
change. A person often moves from pre-awareness of birth to at least one child and breastfed successfully.
a recommended practice to awareness, contemplation Lay counsellors may not have so much in common
of trying the new practice, trial of the practice, adop- with those whom they help, and may not have breast-
tion of the practice, maintenance, and finally advo- feeding experience. However, both can be effective if
cacy of the new practice (13). committed and well trained. They may provide indi-
vidual counselling, visit the homes of pregnant or
When communicators understand this process, they
breastfeeding women, lead support groups, give talks
can identify the stage of their target group, and then
to community groups, or work alongside a commu-
can design a strategy to move them to the next stage.
nity health worker in a health facility.
For someone in the “pre-awareness” stage, the most
important need is information. If a person is con- Peer and lay counsellors can be trained in necessary
templating trying out what he or she has learned, skills using local adaptations of the courses developed
it is useful to encourage him or her, and to provide for health workers (18). They need an on-going con-
opportunities to try it. If a person is already trying nection to someone who can support them to sustain
a new practice, the health workers should emphasise their efforts, and to whom they can refer difficult cas-
the benefits and help him or her to overcome resist- es. This support may be a health worker or a health
ance from family or community, through home visits facility, or a NGO.
and support groups.
9.3.4 Fostering breastfeeding support groups
Moving from one stage of change to another requires
a mixture of communication approaches, including Breastfeeding support groups, or mother-to-mother
mass, electronic and print media; community advo- support groups, enable mothers to encourage and assist
cacy and events; and interpersonal communication each other to establish and sustain breastfeeding (19).
(community groups, individual counselling, mother- They can also support appropriate complementary
to-mother support groups and home visits). These feeding. A hospital that is designated Baby-friendly is
approaches need to be directed towards mothers and required, when discharging a mother, to refer her to
family members, community leaders, and others who a breastfeeding support group, if there is one nearby,
are influential in the community. and to foster and promote the establishment of such
groups (see Step 10 in Session 4.7).
9.3.2 Training and support of community health workers Group meetings are led by members with experi-
Community health workers can be important agents ence and some training, but depend on a sense of
of change in a community and provide services to equality and acceptance, which encourages moth-
support infant and young child feeding (14). How- ers to share experiences, ask questions and help each
ever, to do so effectively they need to be trained in other in a familiar, non-threatening community set-
the requisite knowledge and skills, and be supported ting. Breastfeeding support groups can be initiated
by supervisors and more highly-skilled health work- by health workers from primary and referral level
ers to practise accordingly. WHO and UNICEF have facilities, community health workers, or lay or peer
developed several courses that can be used for such counsellors.
training (15,16). Research shows that infant and
young child feeding counselling provided by commu- 9.3.5 Health workers’ roles in supporting community-based
nity health workers can improve caregiver knowledge approaches
and practices and lead to improved health outcomes Involvement of the health sector is necessary for
including child growth. community-based approaches to succeed (12). Health
workers’ supporting roles include:
9.3.3 Training and support of lay and peer counsellors
K Helping with the training of lay or peer counsel-
Health workers often do not have enough time to lors;
provide all the help that mothers and families need.
Peer and lay counsellors can extend the reach of K Providing feedback to lay or peer counsellors when
health services, and provide more easily-accessible they refer infants with feeding difficulties;
infant and young child feeding counselling (17). Peer K Initiating and participating in breastfeeding sup-
counsellors have a similar background to those whom port group meetings to provide information and
they help; they typically are women who have given discuss appropriate feeding practices;
Faculty Guide to integration Breastfeeding in University Curricula
96
86 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
In 2008, WHO and partners issued a set of indicators 5. ILO. Maternity protection convention No. 183. Gene-
for assessing infant and young child feeding practices va, International Labour Organization, 2000.
(20). The indicators are intended for use in large-scale 6. United Nations. Convention on the rights of the
population-based surveys such as Demographic and child. New York, United Nations, 1989.
Health Surveys, and Multiple Indicator Cluster Sur-
veys. They provide information on key dimensions 7. WHO. International code of marketing of breast-
of appropriate infant and young child feeding, in milk substitutes: frequently asked questions. Gene-
accordance with the Guiding principles for comple- va, World Health Organization, 2006.
mentary feeding of the breastfed child (21) and the 8. WHO, UNICEF. Integrated management of child-
Guiding principles for feeding non-breastfed chil- hood illness: chartbook and training course. Geneva,
dren 6–23 months of age (22). A summary list of the World Health Organization, 1995.
core indicators and their definitions is in Annex 4. In
addition to population-based coverage data, periodic 9. Santos I et al. Nutrition counseling increases
assessment of quality care in health facilities (23) and weight gain among Brazilian children. Journal of
of progress towards the attainment of the operational Nutrition, 2001, 131(11):2866–2873.
targets defined by the Global Strategy is also impor- 10. Zaman S, Ashraf RN, Martines J. Training in
tant to increase the proportion of infants and young complementary feeding counselling of health care
children who are reached by effective feeding inter- workers and its influence on maternal behaviours
ventions (24). and child growth: a cluster-randomized trial in
Lahore, Pakistan. Journal of Health, Population
and Nutrition, 2008, 26(2):210–222.
11. WHO, UNICEF, BASICS. Nutrition essentials: a
guide for health managers. Geneva, World Health
Organization, 1999.
12. WHO. Community-based strategies for breastfeed-
ing promotion and support in developing countries.
Geneva, World Health Organization, 2003.
13. Prochaska JO, DiClemente CC. Transtheoreti-
cal therapy toward a more integrative model of
change. Psychotherapy: Theory, Research and Prac-
tice, 1982, 19(3): 276–287.
14. Bhandari N et al. An educational intervention
to promote appropriate complementary feed-
ing practices and physical growth in infants and
Practice your counseling skills: 97
In the following clinical case scenarios, the student uses his or her counseling skills (open ended questions
reflecting back, accepting and empathizing) to identify mother concerns, additionally he or she can use probing
Questions for additional information.
1
Reference: WHO/UNICEF. Acceptable medical reasons for use
of breast-milk substitutes. World Health Organization, Geneva,
2008.
Faculty Guide to integration Breastfeeding in University Curricula
100
90 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
Maternal conditions that may justify permanent avoidance K Substance use2 (11):
of breastfeeding — maternal use of nicotine, alcohol, ecstasy,
K HIV infection:1 if replacement feeding is accept- amphetamines, cocaine and related stimulants
able, feasible, affordable, sustainable and safe has been demonstrated to have harmful effects
(AFASS) (6). on breastfed babies;
— alcohol, opioids, benzodiazepines and canna-
Maternal conditions that may justify temporary avoidance
bis can cause sedation in both the mother and
of breastfeeding
the baby.
K Severe illness that prevents a mother from caring
for her infant, for example sepsis. Mothers should be encouraged not to use these
substances and given opportunities and support to
K Herpes simplex virus type 1 (HSV-1): direct con- abstain.
tact between lesions on the mother’s breasts and
the infant’s mouth should be avoided until all
References
active lesions have resolved.
1. Technical updates of the guidelines on Integrated
K Maternal medication: Management of Childhood Illness (IMCI). Evidence
— sedating psychotherapeutic drugs, anti-epilep- and recommendations for further adaptations.
tic drugs and opioids and their combinations Geneva, World Health Organization, 2005.
may cause side effects such as drowsiness and 2. Evidence on the long-term effects of breastfeeding:
respiratory depression and are better avoided if systematic reviews and meta-analyses. Geneva,
a safer alternative is available (7); World Health Organization, 2007.
— radioactive iodine-131 is better avoided given 3. León-Cava N et al. Quantifying the benefits of
that safer alternatives are available – a mother breastfeeding: a summary of the evidence. Wash-
can resume breastfeeding about two months ington, DC, Pan American Health Organization,
after receiving this substance; 2002 (http://www.paho.org/English/AD/FCH/BOB-
— excessive use of topical iodine or iodophors (e.g., Main.htm, accessed 26 June 2008).
povidone-iodine), especially on open wounds 4. Resolution WHA39.28. Infant and Young Child
or mucous membranes, can result in thyroid Feeding. In: Thirty-ninth World Health Assembly,
suppression or electrolyte abnormalities in the Geneva, 5–16 May 1986. Volume 1. Resolutions
breastfed infant and should be avoided; and records. Final. Geneva, World Health Organi-
— cytotoxic chemotherapy requires that a mother zation, 1986 (WHA39/1986/REC/1), Annex 6:
stops breastfeeding during therapy. 122–135.
Growth standards
In 1993 the World Health Organization (WHO) and related information from 8440 healthy breastfed
undertook a comprehensive review of the uses and infants and young children from diverse ethnic back-
interpretation of anthropometric references. The grounds and cultural settings (Brazil, Ghana, India,
review concluded that the NCHS/WHO growth refer- Norway, Oman and USA). The weight-for-age charts
ence, which had been recommended for international presented in this Annex are part of these standards.
use since the late 1970s, did not adequately represent The selection of standard deviations (SD) curves and
early childhood growth and that new growth curves the presentation of the charts are adapted for use in
were necessary. The World Health Assembly endorsed the IMCI context, with weekly divisions in the first
this recommendation in 1994. The WHO Multicentre two months and monthly divisions from 2 to 60
Growth Reference Study (MGRS) was undertaken months of age. Expanded reference tables necessary
in response to that endorsement and implemented for construction of national child health records are
between 1997 and 2003 to generate new curves for available at http://www.who.int/childgrowth/stand-
assessing the growth and development of children the ards/weight_for_age/en/index.html, where there are
world over. The MGRS collected primary growth data detailed instructions on how to use them.
Weight (kg)
Faculty Guide to integration Breastfeeding in University Curricula
102
94 InFAnT And YounG CHIld FeedInG – Model CHAPTeR FoR TexTBooks
Weight (kg)
Annex 3: Models for process of becoming Baby Friendly 103
(adapted for university hospital settings)
Phase 4: Establish a BFHI Assessment committee in the Higher Counsel of Universities for BFHI reassessment
Phase 2: 4 D pathways for making the departments in the university hospital Baby friendly
Phase I: Integration of breastfeeding medicine in the curriculum of basic and clinical teaching
Phase 2: 4 D pathways for making the departments in the university hospital Baby friendly
Phase 4: Establish a BFHI Assessment committee in the Higher Counsel of Universities for BFHI reassessment
Faculty Guide to integration Breastfeeding in University Curricula
104 Annex 4: Integration of Baby and Mother Friendly Practices with Safe Childbirth
(adapted from WHO Safe Childbirth Check list, 2015)
Start plotting partograph when Ensure adequate supplies of: If bleeding abnormally: Is mother bleeding abnormally?
cervix ≥4 cm, then cervix should For mother: gloves, alcohol-based hand • Massage uterus If Yes, treat and delay discharge
dilate ≥1 cm/hr rub or soap, clean water, oxytocin 10 • Consider more uterotonic Pulse >110 beats per minute and
• Diastolic BP ≥90 mmHg, 2+ proteinuria, and any: severe headache, visual disturbance, epigastric pain
• Every 30 min: plot HR, units in syringe • Start IV fluids and keep blood pressure <90 mmHg
<30/min
contractions, fetal HR For Baby: sterile blade, cord clamp, mother warm • Start IV and keep mother warm
• Every 2 hrs: plot temperature suction device, bag and mask
of: • Treat cause: uterine atony, • Treat cause (hypovolemic shock)
• Every 4 hrs: plot BP retained placenta/fragments,
chills or foul vaginal discharge?
retained placenta/fragments,
Does mother need to start antibiotics (yes or No) Ask for allergies before Was placenta removed manually or mother temperature ≥38 °C,
Encourage birth companion to Prepare to care for mother immediately Give baby antibiotics if
If bleeding abnormally:
hrs
(adapted from WHO Safe Childbirth Check list, 2015)
• Diastolic BP ≥90 mmHg, 2+ proteinuria, and any: severe headache, visual disturbance, epigastric pain
after birth:
Encourage birth companion to Prepare to care for mother immediately Give baby antibiotics if Give antibiotics to baby if any of:
be present at birth. after birth: antibiotics given to mother • Respiratory rate >60/min or
• Mother’s temperature ≥38°C
Encourage birth companion to Confirm single baby only (not multiple for treatment of maternal <30/min
provide natural pain relief
• History of foul-smelling
ON ADMISSION
provide natural pain relief birth) infection during childbirth • Chest in-drawing, grunting, or
contractions, fetal HR
be present at birth.
vaginal discharge
dilate ≥1 cm/hr
any of:
hrs
support, give light drins t 1. Give oxytocin within 1 minute after or if baby has any of: convulsions
mother, encourage her to birth • Respiratory rate >60/min • Poor movement on stimulation
move, choose positions of her 2. Deliver placenta 1-3 minutes after or <30/min • Baby’s temperature <35°C (and
choice and give emotional birth • Chest in-drawing, grunting, not rising after warming)
support. 3. Massage uterus after placenta is or convulsions or baby’s temperature ≥38°C
delivered • Poor movement on • Stopped breastfeeding well
Are mother or companion 4. Confirm uterus is contracted stimulation • Umbilicus redness extending to
aware of when to call help if • Baby’s temperature <35 °C skin or draining pus
needed? (Danger signs) (and not rising after
warming)
or baby’s temperature ≥38
°C
Call for help if any of: Prepare to care for baby immediately Baby healthy (Apply Steps 4 Baby healthy (Apply Steps 5, 6, 7,
• Bleeding after birth: of Ten Steps of BFHI) 8,9 of Ten Steps of BFHI)
• Severe abdominal pain 1. Dry baby, keep warm in skin to skin & - Encourage first hour skin to - Show mother how to
• Severe headache or visual covered skin to continue up to first breastfeeding
disturbance 2. If not breathing, stimulate and clear breastfeed, - Show side lying or underarm
• Unable to urinate airway - Guide mother to baby position if cesarean
• Urge to push 3. If still not breathing: feeding cues while on skin to - Avoid supplements, bottles or
• clamp and cut cord skin and teats
• clean airway if necessary - Keep baby with mother for - Encourage rooming-in and on
• ventilate with bag-and-mask feeding to the baby cues (on- demand feeding
• shout for help demand) Baby taken to special care:
Arrange special care & - Teach mother to express her
monitoring if any: milk within six hours of birth
• More than 1 month early and for 6-8 times in 24 hours
• Birth weight <2500 grams - Give baby expressed milk by
• Needs antibiotics cup or dropper
• Required resuscitation - Encourage skin to skin care
whenever possible
On Discharge: refer mother to
support group in breastfeeding
(Step 10 of BFHI)
“WHO Safe Childbirth Checklist Implementation Guide” at: www.who.int/patientsafety.
105
97
Faculty Guide to integration Breastfeeding in University Curricula
106 Annex 45
exclusive breastfeeding
2. exclusive breastfeeding under 6 months: Proportion of infants 0–5 months of age who are fed exclusively with
breast milk.
Infants 0–5 months of age who received only breast milk during the previous day
Infants 0–5 months of age
Continued breastfeeding
3. Continued breastfeeding at 1 year: Proportion of children 12–15 months of age who are fed breast milk.
Children 12–15 months of age who received breast milk during the previous day
Children 12–15 months of age
dietary diversity
5. Minimum dietary diversity: Proportion of children 6–23 months of age who receive foods from 4 or more food
groups.
Children 6–23 months of age who received foods from ≥ 4 food groups during the previous day
Children 6–23 months of age
1
Reference: WHO, UNICEF, IFPRI, UC Davis, USAID, FANTA,
Macro International. Indicators for assessing infant and young
child feeding practices. Geneva: World Health Organization,
2008.
ent
ion
& Infant
Disorders
Annex 6: Models of integration of Breastfeeding medicine in university curricula
I- A Conceptual framework for integrating updates in Breastfeeding medicine into the pediatric curriculum
"Breastfeeding is for every child - Breastmilk is for curing sick babies” quotation by Prof. Reda Sanad, Head of Pediatric Dept. in Benha University
on to general Pediatrics
The curriculum was drafted by an expert groups from AlZahraa University Hospital for girls: Prof. Dr Afaf Koraa, Prof. Soheir Fayed, Prof. Somaya AbdelGhani, Prof. Hoda
breastfed.
Metwally, Prof. Tayser ElZayat, (AlAzhar University) and Prof. Azza Abul-Fadl, MCFC & Benha University
Topic ILO for undergraduate Didactic Breastfeeding content Practical/skills Evaluation
related problems
Introduction to general Pediatrics
Growth & 1--To understand differences in growth patterns - WHO growth charts for the breastfed How to use and ILO for undergraduate MCQs/SCQs
Development between breastfed and non-breastfed. infant interpret Written
2--To use the WHO growth charts of breastfed when - Assessing growth of breastfed infants growth charts exams
Nutrition & Infant 3. To understand what is meant by exclusive breastfed Definitions of common terminologies Assessing a MCQs/SCQs
1
3. To understand what is meant by exclusive breastfed
Feeding* infant, on demand feeding, rooming-in, bottle fed and related to breastfeeding breastfeed Written
feed.
infant
intake
5. To list factors affecting breastfeeding (Ten steps/BFHI) Managing breast related problems expression
6. To describe management of breastfeeding and breast Maternal medications and breastfeeding Cup feeding
Milk storage
1
relactate.
Breastmilk
expression
breastfeed
how help a
Positioning
Assessing a
Cup feeding
mother with
I- A Conceptual framework for integrating updates in Breastfeeding medicine into the pediatric curriculum
Demonstrate
Demonstrate
counseling f a
malnourished
growth charts
baby at breast
for vaccination
mother coming
How to express
How to use and
107
exa
exa
exa
feeding is for every child - Breastmilk is for curing sick babies” quotation by Prof. Reda Sanad, Head of Pediatric Dept. in Benha Univers
Wri
Wri
Wri
Ora
Ora
Ora
Ora
Practical/skills Eva
ulum was drafted by an expert groups from AlZahraa University Hospital for girls: Prof. Dr Afaf Koraa, Prof. Soheir Fayed, Prof. Somaya AbdelGhani, Prof. Ho
MCQ
MCQ
MCQ
deficiencies
4-- To understand the role of optimal practices for
breastfeeding that lead to under or
overweight
and cup feed
during illness 108
preventing malnutrition disorders and techniques for - Preventive role of breastfeeding against
treating them. later obesity – mechanism and side effects
Neonatology 1- To describe the current recommendation of infant - Composition & benefits of preterm How to express MCQs/SCQs
feeding. breastmilk to preterm and store Written
2- To recognize and list infant feeding cues. - Feeding preterm & feeding reflexes & Positioning of exams
3- To describe the value of preterm breastmilk feeding in coordination preterm Oral and
preventing and reducing complications in the preterm - Variations in breastmilk in health & Cup feeding clinical exam
baby. disease & in the same feed and tube
3- To describe how to assess and support a mother with - Definition & benefits of KMC feeding
a LBW baby. - EBM & Wet nurse feeding KMC
4-To define list indications, technique and storage of
expressed breastmilk
Social & Preventive 1. Identify the importance of early STS, continued Environmental benefits of breastfeeding Demonstrate MCQs/SCQs
Pediatrics breastfeeding and gradual weaning in bonding, for reducing mortality and morbidity how to help Written
attachment in preventing psychosocial and Psychosocial benefits: Effects of STS on mother to give exams
behavioural development of the infant. bonding and attachment more skin to Oral and
2. Explain the economic and environmental benefits of Education of working breastfeeding skin care and clinical exam
breastfeeding. mothers on how to continue to breastfeed how to
3. To list the benefits of breastfeeding to the working by expressing and storing her milk and continue
mother and her baby and her workplace. feeding it to her baby by cup spoon breastfeeding
with work
Genetics & 1-To list the benefits of breastfeeding to babies with Management of breastfeeding in Positioning of Oral exams
Dysmorphology Down syndrome and other chromosomal abnormalities. anomalies as cleft palate and trisomies or baby with and clinical
2-To describe how to breastfeed infants with other facial anomalies. exams
dysmorphology or hypotonia. The genetic basis of breastmilk and
breastfeeding
Specialty Pediatrics
Cardiovascular 1- To list the benefits of breastfeeding for babies with CVS hemodynamics of breastfed Demonstrate MCQs/SCQs
Diseases congestive heart failure Benefits of BM for baby with CHD or CHF how to maintain Written
2- To identify the value of breastfeeding in later (low salt, improved oxygenation …) breastfeeding, exams
protection against atherosclerosis, hypertension Managing heart failure in breastfed express and cup Oral and
coronary heart disease How to increase caloric intake of baby feed during clinical
3- To describe the benefits of continuing breastfeeding in with CHD or CHF (with EBM) illness and how exams
babies with congenital heart defects and how to to increase
manage breastfeeding in these children. supply during
Faculty Guide to integration Breastfeeding in University Curricula
2
convalescence
Respiratory Diseases 4- To demonstrate the protective value of breastmilk and - Benefits of exclusive breastfeeding for MCQs/SCQs
breastfeeding in preventing and decreasing severe the asthmatic or URTI (especially OM, sore Written
URTI, LRTI and aspiration pneumonia. throat and streptococcal disease). exams
5- To list the benefits of exclusive and continued - Effect of breastfeeding on asthma and Oral and
breastfeeding in alleviation of asthma and preventing other allergies clinical exam
recurrent attacks. - Management of BF in a child with LRTI
6- 3- To describe the management of breastfeeding in
URTI, LRTI and asthma.
Hematology & 7- 1-To explain the importance of early and adequate -Hyperbilirubinemia due to inadequate Demonstrate MCQs/SCQs
Oncology breastfeeding in prevention and treatment of neonatal breastfeeding and its management how to express Written
jaundice (physiological and breastmilk) -How breastfeeding protects against child and cup feed exams
8- To illustrate the bioavailability of breastmilk iron in leukemia and lymphoma during Oral exams
preventing iron deficiency anemia during exclusive -Baby exposure to irradiation or cancer irradiation and
breastfeeding and role of microbiota in first 6 months. medication can continue breastfeeding chemotherapy
9- To list the benefits of breastfeeding against cancer in -Supporting baby/mother dyad post (and how to
baby (leukemia) and mother. surgery to continue breastfeeding protect mother’s
10- The management of infant feeding in mothers with (maternal exposure to irradiation or milk from
cancer, previous cancer and surgery. cancer medications as an indication for irradiation)
surrogate mother or treated donor milks)
Infectious diseases 11- To describe how colostrum can protect against Anti-infective properties of breastmilk Demonstrate MCQs/SCQs
infection in the early postpartum days Continuing breastmilk feeding in a sick how to express Written
12- To define the protective values of different bioactive child and cup feed exams
factors in breastmilk Maternal infections that contraindicate during acute Oral exams
13- To manage breastfeeding in case of maternal breastfeeding illness
infection
Endocrinology 14- Describe the hormonal control of lactation Benefits of breastfeeding and skin care in Demonstrate MCQs/SCQs
15- Describe the effect of breastfeeding on prevention psychosocial short stature how to express Written
hypothyroidism and hyperthyroidism. Managing breastfeeding in a child with and cup feed exams
16- To describe how to support a mother in hypo or hyperthyroidism, DM during illness Oral and
breastfeeding her baby with hypothyroidism and Protective role of Breastfeeding against with diabetic clinical exam
hyperthyroidism. development of DM coma &
17- To describe the role of breastfeeding in preventing (Supporting a diabetic mother to continue positioning of
hypoglycemia. exclusive breastfeeding) hypothyroid
Neuromuscular disease 18- To list the components of breastmilk related to brain How breastfeeding promotes IQ and Demonstrate MCQs/SCQs
development cognitive development how to use Written
19- Describe how breastfeeding exclusivity and duration Breastfeeding baby with CP or other swaddling to exams
can influence IQ and cognitive development of the neurological condition breastfeed a Oral and
3
109
child Supporting mother with epilepsy or on
20- To assist mothers with hypotonic or hypertonic baby psychiatric medications
hypertonic baby
-Demonstrate
clinical exam
110
to breastfeed (positioning and attachment) how to use
21- To explain how to support mothers with epilepsy to saddling to
continue breastfeeding and to list the psychosocial breastfeed
benefits of breastfeeding to mother with neurological floppy baby
condition
Gastroenterology & 22- To explain the role of breastfeeding in preventing -Benefits of BF in preventing diarrheal Demonstrate MCQs/SCQs
Hepatology diarrheal diseases disease and long term on reducing CIBD how to express Written
23- To explain the importance of continued (Chron disease and Ulcerative colitis) and cup feed exams
breastfeeding while applying plan A and B of How to continue breastfeeding during during illness Oral exams
management of diarrheal disease (IMCI) diarrhea and dehydration
24- To explain the value of breastfeeding during and Management of lactose intolerance in
after diarrheal disease to prevent dehydration, breastfed babies
malnutrition and to enhance repair of intestinal Continue breastfeeding with in mothers
mucosa and babies with hepatitis B or C
Renal Disease 25- Describe the importance of breastmilk in feeding - Composition of breastmilk and its low Demonstrate MCQs/SCQs
babies with renal disease solute content and low in protein so does how to express Written
26- Describe how breastfeeding reduces UTI impose on renal function and cup feed exams
27- Describe management of breastfeeding in patients - Feeding baby expressed breastmilk and during illness Oral exams
with renal failure tube feeding
Pediatric emergencies 28- To describe the hazards of infant milk formula - Babies fall sick more often and with less Demonstrate Oral and
donated in emergency situations access to drugs may die how to handle clinical exam
29- To list the benefits of encouraging and supporting - Used as a marketing tactic company
mothers to breastfeed in such situations representatives
Behavioural Pediatrics 30- To explain the negative effect of marketing of BMS International Code of Marketing of Advocate rights MCQs/SCQs
(incl. adolescent on mother decision to breastfeed breastmilk substitutes of working Written
medicine, child abuse, 31- To describe the aim and scope of the code and list The Baby Friendly Hospital Initiative (BFHI) women exams
child advocacy) the summary of the contents of the code The strategy of infant & young child Oral and
32- To be able to identify and monitor the violations to feeding clinical exam
the code Convention of the rights of the child
33- To describe the aim and evidence supporting the
Ten steps of Baby friendly and how to implement
them.
* (Managing babies who are sick or have congenital anomaly or preterm.. ect – please see with individual subspecialty)
For all specialties: Managing mother on medication please refer to: http://www.medsmilk.com/pages/pricing
Faculty Guide to integration Breastfeeding in University Curricula
4
II- A Conceptual Framework for Integrating Updates in Breastfeeding Medicine into Community Medicine
Contributing departments: Community Medicine, Cairo University, Community and Occupational medicine AlAzhar University for Girls, AlAzhar University for boys,
Community Medicine, Benha Faculty of Medicine, and High Institute of Public Health in Alexandria University, in collaboration with EMWA, MCFC, UNICEF-ECO
Topic Intended Learning objectives for undergraduates Suggested Take Home Messages *Evaluation
Determinant 1- Understand the role of breast feeding as a health Proper breastfeeding is an essential determinant of health MCQs
s of Health determinant factor
Nutrition 2- Understand and the types and composition of breastmilk Exclusive breastfeeding (BF) for first 6 months and continued BF for two MCQs
(BM) and hazards of not breastfeeding (BF) years with adequate complementary foods Written &
3- Describe optimal feeding recommendations in the first 6 Exclusively breastfed get all their needs of iron because of the high Oral exams
months and 2 years of life. bioavailability in BM but not vitamin D spots (OSPE)
4- Describe micronutrient needs for breastfed infants Adequate antenatal nutritional stores in the mother protect babies Log books
5- Identify nutritional requirements of pregnant and lactating from micronutrient deficiencies
mothers Only if mother is severely malnourished will the nutritional efficacy of
6- Describe the principles of complementary feeding BM be compromised
7- Describe benefits of exclusive from birth to six months and Introducing complementary food is an important process and should
continued BF into second year follow the essential principles to be done successfully
8- List the hazards of cow’s milk and formula feeding Artificial feeding is risky to the baby and deprives him from the basic
requirements particularly in the first 6 months
Child Health 1- Describe the growth pattern of breastfed Exclusively breastfed have early higher weight gains followed by MCQs
services 2- Describe the significance of use of WHO growth charts for slowing of weight Written
growth monitoring Community infant feeding health facility practices can be corrected by Oral exams
3- List the Ten steps to successful support of BF in a Baby monitoring indicators of optimal BF practices including exclusive BF, spots (OSPE)
friendly facility early timely initiation, avoiding bottles, pacifiers and supplements Log books
4- List BF indicators for the community and for the Baby friendly
hospital Initiative
Maternal 1- Describe content of antenatal education in BF Mother friendly practices that encourage normal vaginal delivery and MCQs
health 2- Discuss immediate postpartum practices that ensure early skin to skin contact and lower MMR spots (OSPE)
services successful BF Baby friendly practices that encourage rooming in, frequent BF and no Log books
3- Discuss practices that lead to common problems in breast and supplements help establish lactation
nipple and baby’s health Avoiding early bottles and showing mothers how to express milk and
4- Discuss harmful postpartum practices that interfere with BF good positioning and latch-on prevents breast or nipple problems in
5- Explain the appropriate responses to the commonest mother and sepsis and jaundice in baby
problems raised by lactating mothers Proper counseling can solve many problems related to malpracticed
breastfeeding
Primary Describe the role of primary health care in the promotion and Adequate breastfeeding support requires strengthening of referral MCQs
health Care integration of BF through the health system systems, quality management and communication systems in PHC Log books
Communica Describe the effect of not breastfeeding on the health, Non breastfed have a risk of mortality 25 times more from diarrheal MCQs
ble diseases morbidity and mortality of infants and cost on medical care disease and 4 times more for lower respiratory tract infections Log books
compared to exclusively breastfed in first 3-6 months of life
Immunizatio 1- Discuss the role of colostrum in developing the immune - Colostrum is rich in immune factors and is the first immunization baby Oral exams
n services system of babies receives in life by establishing the GIT defense mechanisms spots (OSPE)
5
111
Communicat
2- Describe how BF is beneficial for the efficacy of vaccinations
MCQs
112
ion/ Health pregnant and lactating women misinformation and misbeliefs from unprofessional social network Role plays
education 2- Acquire essential communication skills Discuss why good - Misconceptions and misbeliefs may have a negative effect on women’s Log books
communication is necessary for supporting continued BF ability to continue to breastfeed Practical /
3- List the health education messages necessary for pregnant - Use of effective communication skills as, listening with empathy help to field
and lactating women identify these misconceptions, while acceptance, praising, giving activities
4- Apply an appropriate behavior change model to improve information in a positive way and suggestions not commands help
breastfeeding and weaning practices manage them
Mental 1- Discuss the psychosocial benefits of BF to mothers and babies - Early skin to skin contact improves bonding, reduces maternal infant MCQs
health 2- Discuss the impact of early mother-infant separation on the separation disorders, reduces postpartum depression Oral exams
services mental health status of children and on the economy - IQ of breastfed especially when preterm, is significantly higher than spots (OCSE)
non-breastfed but is influenced by hereditary and environmental factors Log books
Occupationa 1- Discuss how to support and protect working BF mothers and - Exposure to irradiation or toxic gases can have negative effects on Oral exams
l health BF workplace friendly mother’s health, unborn fetus and milk production log books
Environment 1- Discuss the health and environmental hazards of infant milk - The waste and toxic substances released by the factories producing MCQs
al Health formula IMF) industry, bottles and artificial nipples infant milk formula and also the manner of disposal of plastics and Oral exams
2- Calculate the cost of pollution (air, food, water) caused by residues from infant milk formula can have negative effects on the spots (OSPE)
IMF, feeding utensils associated with bottle feeding on the environment Log books
health of mothers and children and on the environment - Exposure of infants from water pollution is augmented by bottle feeding
Hygiene and Describe the infection control measures associated with the - Expressed breastmilk is the safest substitute when direct BF is not MCQs
sanitation proper techniques of expression and storage of expressed possible - Handwashing is all that is required prior to BF (no need to Oral exam
breastmilk wash breast), with daily bathing of baby and mother spots (OSPE)
Policy and 1- List the Ten steps to successful support of BF in a Baby - Any organization where BF is taught or BF mother receive service should MCQs
Hospital friendly facility have a written policy that is routinely, disseminated to all its staff Oral exam
Administrati 2- Describe how to write a policy brief to decision makers to (including customers) and monitored for implementation and spots (OSPE)
on support and protect BF improvement purposes Practical;
(Postgraduat 3- Apply BFHI standards to assess its implementation by - Protecting BF is achieved by implementing the international code of Log books
es) healthcare facilities marketing of breastmilk substitutes (ICMBMS)
4- Plan a program to make a hospital Baby friendly - Evidence of cost benefits of the Baby friendly Hospital Initiative (BFHI)
5- Explain what is meant by global criteria and how they are to hospital services is surmount and savings can be used to improve
used in the assessment and designation of BFH services and promote breastfeeding
Health Laws List the laws that promote and protect BF, ministerial decrees - The Egyptian law for protecting the child includes major articles on the MCQs
and their positive effect on BF and drawbacks protection of infant feeding rights to BF and IVCMBMS spots (OSPE)
Research Practice collection of data related to breastfeeding in an - Data collected should be based on the definitions and practices Research
Methodologi accurate and scientifically based manner recommended by the WHO and UNICEF proposals,
es Interpret, criticize and analyze research studies in BF - Research in BF may be biased when there conflict of interest critiques
Family 1- Describe the lactation amenorrhea method (LAM) of - Exclusive BF for babies under six months in a women with amenorrhea MCQs
Planning contraception can reduce pregnancy rates by 98% Oral exams ,
2- Describe the complementarity effect of optimal BF practices - After 6 months Increasing the frequency of BF at night promotes spots (OSPE)
when used with other contraceptive methods anovulatory cycles and acts as a complementary contraceptive Log books
* Other forms of practice and evaluation include presentations, reports, research, assignments, and community activities & skill labs (using simulators as Baby and Breast models)
Faculty Guide to integration Breastfeeding in University Curricula
6
Annex 7: STUDENT COMPETENCIES IN BREASTFEEDING 113
COMPETENCY KNOWLEDGE SKILL
counsel a mother . Give an example of each skill child growth and feeding her infant or young
2. Use Confidence . List the 6 Confidence and Support . Use the Confidence and Support skills
3. Assess a breastfeed . Explain the contents and arrangement . Assess a breastfeed using the Breastfeed
of the Breastfeed Observation Job Aid Observation Job Aid
4. Help a mother to . Explain the 4 key points of . Recognize good and poor positioning according
STUDENT COMPETENCIES IN BREASTFEEDING
oxytocin reflex
position a baby at the positioning to the 4 key points
breast . Describe how a mother should . Help a mother to position her baby using the 4
support her breast for feeding key points (in-line, close, facing, supported), in
. Explain the main positions – sitting, the different positions
reflex
child
child
5. Help a mother to . Describe the relevant anatomy and . Recognize signs of good and poor attachment
. Describe the relevant anatomy and
attach her baby to the physiology of the breast and suckling and effective suckling according to the
1
breast and physiology of lactation
. Describe how a mother should
. Explain the 4 key points of . Help a mother to get her baby to attach to the
KNOWLEDGE
6. Explain to a mother . Describe the physiology of breast . Explain to a mother about the optimal pattern
about the optimal milk production and flow of breastfeeding and demand feeding
breast milk is useful
pattern of
action of the baby
7. Help a mother to . List the situations when expressing . Explain to a mother how to stimulate her
(in CP)
skills
milk by hand - Describe the relevant anatomy of the . Rub a mother’s back to stimulate her oxytocin
breast and physiology of lactation reflex
- Explain how to stimulate the . Help a mother to learn how to prepare a
6. Explain to a mother
attach her baby to the
3. Assess a breastfeed
4. Help a mother to
5. Help a mother to
7. Help a mother to
8. Help a mother to
2. Use Confidence
- Describe how to select and prepare a . Explain to a mother the steps for expressing
Learning skills to
counsel a mother
counsel a mother
breastfeeding
milk by hand
- Describe how to store breast milk . Observe a mother expressing breast milk by
hand and help her if necessary
pattern of
8. Help a mother to . List the advantages of cup-feeding . Demonstrate to a mother how to prepare a cup
breast
breast
1
9. Measure weight,
length and height
. Describe how to measure weight
length and height
baby safely
. Measure weight of a young child held by a
mother and an older child alone
114
. Determine when to measure length . Measure length correctly
and when to measure height . Measure height correctly
10. Plot single points . Explain how to place a point on a . Plot weight and length/height points on weight-
on various growth graph combining information from two for-age and length/height-age charts
charts axes . Plot weight points on weight-for-length/height
. Describe where to find the age, charts
weight, and length/height on various
growth indicator charts
11. Interpret single . Identify growth problems based on . Identify children who are stunted, underweight,
points on various points plotted on a single indicator wasted and overweight based on points plotted
indicator charts chart on several indicator charts
. Define a growth problem using a
combination of indicator charts
12. Interpret growth . Interpret trends on growth charts . Identify a child who are growing normally, has
trends using a a growth problem or is at risk of a growth
combination of problem
indicators
13. Take a feeding . Describe the contents and . Take a feeding history using the job aid and
history for an infant arrangement of the Feeding History appropriate counselling skills according to the
0-6 months Job Aid, 0-6 Months age of the child
14. Teach a mother . List and explain the 6 Key Messages . Explain to a mother the 6 Key Messages about
the 10 Key Messages about what to feed to an infant or what to feed to an infant or young child to fill the
for complementary young child to fill the nutrition gaps nutrition gaps (Key Messages 1-6)
feeding (Key Messages 1-6) . Use the food consistency pictures appropriately
. Explain when to use the food during counselling
consistency pictures, and what each . Explain to a mother the 2 Key Messages about
picture shows quantities of food to give to an infant or young
. List and explain the 2 Key Messages child (Key Messages 7-8)
about quantities of food to give to an . Explain to a mother the Key Message about
infant or young child (Key Messages how to feed an infant or young child (Key
7-8) Message 9)
. List and explain the Key Message . Explain to a mother the Key Message about
about how to feed an infant or young how to feed an infant or young child during
child during illness (Key Message 10) illness (Key Message 10)
15. Counsel a . List the Ten Steps to Successful . Use counselling skills appropriately with a
pregnant woman Breastfeeding pregnant woman to discuss the advantages of
about breastfeeding . Describe how the International Code exclusive breastfeeding
of Marketing of Breast-milk . Explain to a pregnant woman how to initiate
Substitutes helps to protect and establish breastfeeding after delivery, and
breastfeeding the optimal breastfeeding pattern
. Discuss why exclusive breastfeeding . Apply competencies 1, 2 and 6
is important for the first six months
16. Help a mother to . Discuss the importance of early . Help a mother to initiate skin-to-skin contact
initiate breastfeeding contact after delivery and of the baby immediately after delivery and to introduce her
receiving colostrum baby to the breast
Faculty Guide to integration Breastfeeding in University Curricula
2
. Describe how health care practices . Apply competencies 1, 2, 4 and 5
affect initiation and exclusive http://www.breastmilksolutions.com/index.html
breastfeeding
17. Support exclusive . Describe why exclusive breastfeeding . Apply competencies 1 to 8 and 13 appropriately
breast feeding for the is important http://www.bfmed.org/Resources/Protocols.aspx
first six months of life . Describe the support that a mother http://www.breastmilksolutions.com/index.html
needs to sustain exclusive
breastfeeding
18. Help a mother to . Describe the importance of breast . Apply competencies 1, 2, 12 and 14, including
sustain breastfeeding milk in the 2nd year of life explaining the value of breastfeeding up to 2
up to 2 years of age or years and beyond
beyond http://www.breastmilksolutions.com/index.html
19. Help a mother . Describe the common reasons why a . Apply competencies 1, 3, 12 and 13 to decide
with ‘not enough baby may have a low breast milk the cause
milk’ intake . Apply competencies 2, 4, 5, 6, 7 and 8 to
. Describe the common reasons for overcome the difficulty, including explaining the
apparent insufficiency of milk cause of the difficulty to the mother
. List the reliable signs that a baby is http://www.bfmed.org/Resources/Protocols.aspx
not getting enough milk
20. Help a mother . List the causes of frequent crying . Apply competencies 1, 3, 12 and 13 to decide
with a baby who cries . Describe the management of a crying the cause
frequently baby . Apply competencies 2, 4, 5 and 6 to overcome
the difficulty, including explaining the cause of
the difficulty to the mother
. Demonstrate to a mother the positions to hold
and carry a colicky baby
21. Help a mother . List the causes of breast refusal . Apply competencies 1, 3, 12 and 13 to decide
whose baby is . Describe the management of breast the cause
refusing to breastfeed refusal . Apply competencies 2, 4 and 5 to overcome the
difficulty, including explaining the cause of the
difficulty to the mother
. Help a mother to use skin-to-skin contact to
help her baby accept the breast again
Apply competencies 7 and 8 to maintain breast
milk production and to feed the baby meanwhile
22. Help a mother to . Explain why breast milk is important . Help a mother to feed her LBW baby
breastfeed a low- for a low-birth-weight baby or sick appropriately
birth-weight baby or baby . Apply competencies, especially 7, 8 and 12, to
sick baby . Describe the different ways to feed manage these infants appropriately
breast milk to a low-birth-weight baby . Explain to a mother the importance of
List the special properties of colostrum breastfeeding during illness and recovery
23.. Help mothers . List the gaps which occur after six . Apply competencies 1, 2, 12 and 14
whose babies are over months when a child can no longer get . Use the FOOD INTAKE JOB AID, 6-23
six months of age to enough nutrients from breast milk MONTHS to learn how a mother is feeding her
give complementary alone infant or young child
feeds . List the foods that can fill the gaps . Identify the gaps in the diet using the FOOD
. Describe how to prepare feeds INTAKE JOB AID, 6-23 MONTHS and the
hygienically FOOD INTAKE REFERENCE TOOL, 6-23
3
115
24. Help a mother
who has flat or
. Explain the difference between flat
and inverted nipples and about
MONTHS
. Recognize flat and inverted nipples
. Apply competencies 2, 4, 5, 7 and 8 to
116
inverted nipples protractility overcome the difficulty
. Explain how to manage flat and . Show a mother how to use the syringe method
inverted nipples for the treatment of inverted nipples
25. Help a mother . Explain the differences between full . Recognize the difference between full and
with engorged breasts and engorged breasts engorged breasts
. Explain the reasons why breasts may . Apply competencies 2, 4, 5, 6 and 7 to manage
become engorged the difficulty
. Explain how to manage breast http://www.bfmed.org/Resources/Protocols.aspx
engorgement
26. Help a mother . List the causes of sore or cracked . Recognize sore and cracked nipples
with sore or cracked nipples . Recognize candida infection of the breast
nipples . Describe the relevant anatomy and . Apply competencies 2, 3, 4, 5, 7 and 8 to
physiology of the breast manage these conditions
. Explain how to treat candida infection http://www.mombaby.org/wp-
of the breast content/uploads/2016/04/PainProtocols.v3.pdf
27. Help a mother . Describe the difference between . Recognize mastitis and refer if necessary
with mastitis engorgement and mastitis . Recognize a blocked milk duct
. List the causes of a blocked milk duct . Manage blocked duct appropriately
. Explain how to treat a blocked milk . Manage mastitis appropriately using
duct competencies 1, 2, 3, 4, 5, 6, 7, 8 and rest,
. List the causes of mastitis analgesics and antibiotics if indicated. Refer to
. Explain how to manage mastitis, the appropriate level of care
including indications for antibiotic http://www.mombaby.org/wp-
treatment and referral content/uploads/2016/04/PainProtocols.v3.pdf
. List the antibiotics to use for infective
mastitis
Counsel a mother . Describe causes of stunting, wasting, . Identify the key sections of the job-aid
whose child has and underweight Investigating causes of undernutrition
undernutrition . Involve the mother in identifying . Use the job-aid appropriately (find the correct
possible causes of her child's pages for the child's age, complete the
undernutrition investigation before counselling, counsel using
. Find age-appropriate advice for the age-appropriate recommendations)
problem identified . Check mother's understanding using checking
. Set goals for improving growth of an questions
undernourished child . Involve mother in setting goals for improved
growth
29. Counsel a mother . Describe causes of . Identify the key sections of the job-aid
whose child is overweight/obesity INVESTIGATE CAUSES OF OVERWEIGHT
overweight . Involve the mother in identifying . Use the job-aid appropriately (find the correct
possible causes of her child's pages for the child's age, complete the
overweight investigation before counselling, counsel using
. Set goals for improving growth of an age-appropriate recommendations) . Check
overweight child mother's understanding using checking questions
Adapted from the Training course of IYCF . Involve mother in setting goals for improved
growth
Faculty Guide to integration Breastfeeding in University Curricula
4
POST TEST 117
Q Q
1 The recommended treatment of symptomatic 5 The mother of a breastfed infant is going to have
hypoglycemia includes all of the following EXCEPT surgery requiring general anaesthesia. How soon after
surgery can she resume breastfeeding?
a) Gavage feeds with glucose water or expressed breast a) 6 hours
milk
b) Breastfeeding on demand once symptoms resolve b) 12–24 hours
c) Glucose monitoring before each feed until glucose is c) 48 hours
stabilized
d) Intravenous glucose using 2 cc/Kg 10% glucose bolus d) 1 week
e) Examination and evaluation to exclude underlying e) When she is fully awake and able to care for herself
illness
2 During the postpartum stay, a breastfeeding mother 6 Although some older studies found a correlation
reports that she is having difficulty getting her infant between breastfeeding and higher intelligence,
to breastfeed. Your best response to this situation more recent studies, which controlled or adjusted
should be to: for other factors have:
a) Explain that most babies have a difficult time starting a) Found no correlation between IQ and breastfeeding
out and to just keep trying duration in full-term infants
b) Advise that the baby may be getting dehydrated, so he is b) Found no correlation between IQ and breast milk
not interested in feeding intake in preterm infants
c) Encourage supplementation until the baby learns to c) Found a small, but statistically significant increase, in
breastfeed IQ and academic performance in breastfed or breast
milkfed infants
d) Discharge the infant, so the mother will be more relaxed d) Found breastfed infants have a 13–15 IQ point
breastfeeding at home advantage over artificially fed infants
e) Request assistance for the mother at the infant’s next e) found a difference that decreased with age
feeding to evaluate the breastfeeding technique
3 An adequately breastfed healthy, term infant can be 7 The primary hormone responsible for milk
expected to have all of the following EXCEPT: synthesis is:
a) Infrequent stools in the first 2 weeks of life a) Estrogen
b) Loss of no more than 8%–10% of birth weight initially, b) Prolactin
with regain of birth weight by 2-3 weeks of age
c) Loose, yellow, seedy stools after most feedings in the c) Progesterone
early weeks of life
d) d) Desire to feed frequently, at least every 2–3 hours d) d) Oxytocin
e) e) Weight gain pattern of 15–30 grams per day e) e) peptide inhibitory factor
beginning with mother’s increased milk production
4 When positioning a newborn to breastfeed, all of the 8 The component of human milk that binds iron
following are correct EXCEPT: locally to inhibit bacterial growth is:
a) a) After a cesarean section delivery, the side-lying or a) Lactoferrin
football hold positions are most comfortable for mother.
b) b) When using the cradle hold, the infant should be b) Transferrin
placed across the mother’s lap, with the infant’s neck
extended and rotated to latch on to the nipple.
c) c) The mother needs to be sitting or lying in a c) Macrophages
comfortable position to relax her shoulders, and back.
d) d) The cross-cradle, usually works well for every mother d) Oligosaccharides
e) e) Alternating or rotating 2 or more breastfeeding e) Secretory IgA
positions may help to prevent nipple discomfort in the
early days after delivery.
Faculty Guide to integration Breastfeeding in University Curricula
118 Q Q
9 Milk production is increased by: 14 Signs of adequate breast milk intake in the first 4–6
weeks include all below EXCEPT:
10 A breastfeeding mother with a 3-month-old infant has a 15 A diagnosis of nipple candidiasis or monilial infection
red, tender, wedge-shaped area at the outer quadrant of 1 of the nipple (thrush) in the mother’s breast can be
breast. She has flu-like symptoms and a temperature of made based on the associated signs of all of the
39°C. Your management includes all of the following following EXCEPT:
EXCEPT:
a) Antibiotics for 10 days a) Burning pain in the breast
b) Extra rest b) Fever, malaise, and headache
c) Interrupt breastfeeding for 48 hour c) Oral thrush in the infant
d) Moist heat to the involved area of breast d) Pink and shiny appearance of the nipples
e) Fever and pain control with acetaminophen e) Nipple tenderness between breastfeedings
11 Poor weight gain in the breastfed infant is MOST 16 Breastfeeding should be temporarily interrupted
OFTEN caused by: when:
a) Low fat content of the milk a) Mothers are undergoing diagnostic tests with
radioactive contrast agents
12 Exclusive breastfeeding (no other foods) is 17 The WHO/UNICEF Baby Friendly Hospital
recommended for the first: Initiative (BFHI) Ten Steps include all of the
following EXCEPT:
a) 2 months a) Infants should be given nothing but breast milk,
unless medically indicated
b) 4 months b) Infants should room in with their mothers
c) 6 months c) Mothers should be informed of the benefits and
management of breastfeeding
9 months d) Infants should be given pacifiers to improve their suck
coordination
e) 12 months e) Infants be put to breast within the first 30 minutes
after should birth
13 Breastfeeding jaundice is reduced by: 18 Markers of failure to thrive in the breastfed infant
include:
a) Frequent feedings at the breast (8–12 times per 24 a) Maximum weight loss of >8% of birth weight
hours)
b) Water after breastfeeding, given by dropper b) Failure to gain 8–10 oz per week
c) Supplemental glucose water c) Weight loss after day 5
d) Letting the baby sleep more d) Under birth weight by day7
e) All of the above e) a and c
Q Q 119
19 An acceptable medical reason to supplement a 23 For approximately what length of time do you
breastfed infant in the hospital is: recommend exclusive breastfeeding?
a) To quiet a fussy baby a) 1 month
b) Separation due to maternal or infant illness b) 2 months
c) To teach the baby to take a bottle for later c) 4 months
d) To prevent dehydration d) 6 months
e) To allow the mother to rest e) 9 months
20 When women believe they have a low milk supply, 24 How frequently do you usually recommend that
they can BEST be helped by: infants be breastfed during the first week of life?
a) Supplementing the baby by cup or finger-feeding to give a) Every hour
the mother a break
b) Taking a breastfeeding history and assessing the infant b) Every 2 hours
at the breast
c) Having the mother pump for 15 minutes after every c) Every 3 hours
feeding
d) Teaching the mother to assess urine output d) Every 4 hours
e) Reassurance that it is only an infant growth spurt — that e) Whenever the baby seems hungry or fussy (i.e., on
her milk supply is adequate demand), approximately 8–12 times per d ay
21 When do you usually schedule the first postnatal 25 How frequently do you usually recommend that
office visit for an infant discharged to home? infants be breastfed during the first month of life?
a) At 3–5 days of life a) Every hour
b) At 2 weeks of life b) Every 2 hours
c) At 1 month of life c) Every 3 hours
d) At 2 months of life d) Every 4 hours
e) Any of the above is acceptable e) Whenever the baby seems hungry or fussy (i.e., on
demand), approximately 8–12 times per day
The Model Chapter on Infant and Young Child Feeding is intended for
use in basic training of health professionals. It describes essential
knowledge and basic skills that every health professional who
works with mothers and young children should master. The Model
Chapter can be used by teachers and students as a complement to
textbooks or as a concise reference manual.